Laparoscopic and open liver resection for hepatocellular carcinoma with Child-Pugh B cirrhosis: multicentre propensity score-matched study.

BACKGROUND: Laparoscopic liver resection for hepatocellular carcinoma (HCC) in Child-Pugh A cirrhosis has been demonstrated as beneficial. However, the role of laparoscopy in Child-Pugh B cirrhosis is undetermined. The aim of this retrospective cohort study was to compare open and laparoscopic resection for HCC with Child-Pugh B cirrhosis. METHODS: Data on liver resections were gathered from 17 centres. A 1 : 1 propensity score matching was performed according to 17 predefined variables. RESULTS: Of 382 available liver resections, 100 laparoscopic and 100 open resections were matched and analysed. The 90-day postoperative mortality rate was similar in open and laparoscopic groups (4.0 versus 2.0 per cent respectively; P = 0.687). Laparoscopy was associated with lower blood loss (median 110 ml versus 400 ml in the open group; P = 0.004), less morbidity (38.0 versus 51.0 per cent respectively; P = 0.041) and fewer major complications (7.0 versus 21.0 per cent; P = 0.010), and ascites was lower on postoperative days 1, 3 and 5. For laparoscopic resections, patients with portal hypertension developed more complications than those without (26 versus 12 per cent respectively; P = 0.002), and patients with a Child-Pugh B9 score had higher morbidity rates than those with B8 and B7 (7 of 8, 10 of 16 and 21 of 76 respectively; P < 0.001). Median hospital stay was 7.5 (range 2-243) days for laparoscopic liver resection and 18 (3-104) days for the open approach (P = 0.058). The 5-year overall survival rate was 47 per cent for open and 65 per cent for laparoscopic resection (P = 0.142). The 5-year disease-free survival rate was 32 and 37 per cent respectively (P = 0.742). CONCLUSION: Patients without preoperative portal hypertension and Child-Pugh B7 cirrhosis may benefit most from laparoscopic liver surgery.

Liver Transplant Waitlist Outcomes and the Allocation of Hepatocellular Carcinoma Model for End-Stage Liver Disease Exception Points at a Low-Volume Center.

BACKGROUND: Organ scarcity continues to be the main problem limiting the number of liver transplants performed. Outcomes of patients waitlisted for an organ in an Asian country with low organ donation rate have not been well evaluated. Our current policy of allocating 15 exception points to patients with hepatocellular carcinoma (HCC) to render them competitive for a transplant also requires review. METHODS: The waiting list registry and the organ transplant registry of a single institution in Asia were reviewed from December 2005 to June 2016 for all patients who underwent liver transplantation. Patient characteristics and outcomes of waitlist dropouts were evaluated. Statistical analyses were performed using SPSS version 20.0. RESULTS: One hundred seventy-three patients were waitlisted for a deceased donor liver-only transplant. The most common etiology of liver disease was hepatitis B, followed by cholestatic diseases. Approximately half of the patients had HCC (45.6%). Priority listing for transplant comprised 15.6% of cases. Median Model for End-Stage Liver Disease (MELD) at listing was 15, and median waiting time to transplant was 17 weeks (interquartile range = 6.5-43.5). Overall, 89 (51.4%) patients underwent liver transplantation and 68 (39.3%) dropped out. For patients with HCC, the most common cause of dropout was progression beyond University of California San Francisco transplant criteria (62.5%). The cumulative incidence of dropout at 3 months among patients with HCC who received exception MELD scores was 11%. This was higher than those listed with physiologic MELD of 14-16 points (7%) but lower than those with 17-19 points (16%). CONCLUSIONS: Hepatitis B-related liver disease and HCC comprise the majority of patients listed for liver transplant. Dropout rates are high and this is due to the lack of donor organs. The current policy of allocating 15 exception MELD points to patients with HCC within transplant criteria may underestimate the dropout risk of patients with HCC in our population.

Outcome after laparoscopic versus open wedge resection for suspected gastric gastrointestinal stromal tumors: A matched-pair case-control study.

BACKGROUND: Laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) has been shown by several retrospective studies to be technically feasible and associated with favorable outcomes when compared to the open approach. This study aims to mitigate potential selection bias by performing a case control study of laparoscopic (LWR) versus open wedge resection (OWR) matched by resection type, location and tumor size. METHODS: We retrospectively identified 50 consecutive patients who underwent LWR for a suspected gastric GIST from a prospective database and matched this cohort with 50 patients who underwent OWR. RESULTS: There was no statistical difference between the key baseline clinicopathological features of patients' who underwent LWR versus OWR. Patients who underwent LWR had longer operating times [150 (range, 65-270) minutes vs 92.5 (25-200) minutes, P < .001] but decreased median blood loss [0 (0-300) ml vs 0 (0-1200) ml, P = .015], decreased frequency of intraoperative or postoperative blood transfusion [1 (2%) vs 8 (16%), P = .031], decreased median time to liquid diet [2 (0-5) vs 3 (1-7) days, P < .001], decreased median time to solid diet [3 (1-6) vs 5 (2-11) days, P < .001] and decreased postoperative stay [4 (2-10) vs 4.5 (3-17), P < .001] compared to OWR. There was no difference in oncological outcomes such as frequency of close margins (≤ 1 mm) and recurrence-free survival. CONCLUSION: This matched case-control study provides supporting evidence that LWR results in superior perioperative outcomes compared to OWR without compromising on oncological outcomes.

Simplified noncultured autologous cell grafting for the treatment of chronic nonhealing ulcers: the six-well plate technique.

Chronic recalcitrant ulcers are associated with severe morbidity, and there are few effective treatment options available. Living skin substitutes are an important form of adjuvant therapy to enhance healing of such wounds. We investigated a novel, simplified, noncultured, autologous, cell grafting procedure, using a six-well plate technique, to treat chronic recalcitrant wounds. This was a prospective pilot study that involved harvesting an ultrathin split-skin graft from the gluteal region, which was washed, separated and prepared in six different wells to obtain an autologous mixture of keratinocytes, melanocytes and fibroblasts; this was subsequently applied directly to the wound using a hyaluronic acid (HA) matrix. Eight patients with a total of 14 ulcers were recruited. The primary endpoint assessed was the percentage of re-epithelialization of the ulcers. Secondary endpoints included quality of life and wound bed indices. At baseline, the median wound surface area was 7.4 cm(2) (mean 17.6 ± 23.6 cm(2) , range 0.5-80.0 cm(2) ) with a median duration of 18 months (mean 70.2 ± 95.9, range 3-216 months). The median wound surface area was reduced by 74.3%, from 7.4-1.9 cm(2) , at the final visit. Overall, 28.3% of the ulcers achieved complete healing, and 71.3% of the ulcers had reduction in wound size. Post-graft, there was also improvement in secondary wound bed parameters and all quality of life domains of the Cardiff Wound Impact Schedule. These results suggest that this noncultured autologous six-well technique might be beneficial for treating recalcitrant ulcers.

Adjuvant hepatic intra-arterial iodine-131-lipiodol following curative resection of hepatocellular carcinoma: a prospective randomized trial.

BACKGROUND: The purpose of the present study was to determine whether intrahepatic injection of (131)I-lipiodol (Lipiodol) is effective against recurrence of surgically resected hepatocellular carcinoma (HCC). METHODS: From June 2001 through March 2007, this nationwide multi-center prospective randomized controlled trial enrolled 103 patients 4-6 weeks after curative resection of HCC with complete recovery (52: Lipiodol, 51: Control). Follow-up was every 3 months for 1 year, then every 6 months. Primary and secondary endpoints were recurrence-free survival (RFS) and overall survival (OS), respectively, both of which were evaluated by the Kaplan-Meier technique and summarized by the hazard ratio (HR). The design was based on information obtained from a similar trial that had been conducted in Hong Kong. RESULTS: The Lipiodol group showed a small, and nonsignificant, improvement over control in RFS (HR = 0.75; 95 % confidence interval [95 % CI] 0.46-1.23; p = 0.25) and OS (HR = 0.88; 95 % CI 0.51-1.51; p = 0.64). Only two serious adverse events were reported, both with hypothyroidism caused by (131)I-lipiodol and hepatic artery dissection during angiography. CONCLUSIONS: The randomized trial provides insufficient evidence to recommend the routine use of (131)I-lipiodol in these patients.

Revised classification/nomenclature of vitiligo and related issues: the Vitiligo Global Issues Consensus Conference.

During the 2011 International Pigment Cell Conference (IPCC), the Vitiligo European Taskforce (VETF) convened a consensus conference on issues of global importance for vitiligo clinical research. As suggested by an international panel of experts, the conference focused on four topics: classification and nomenclature; definition of stable disease; definition of Koebner's phenomenon (KP); and 'autoimmune vitiligo'. These topics were discussed in seven working groups representing different geographical regions. A consensus emerged that segmental vitiligo be classified separately from all other forms of vitiligo and that the term 'vitiligo' be used as an umbrella term for all non-segmental forms of vitiligo, including 'mixed vitiligo' in which segmental and non-segmental vitiligo are combined and which is considered a subgroup of vitiligo. Further, the conference recommends that disease stability be best assessed based on the stability of individual lesions rather than the overall stability of the disease as the latter is difficult to define precisely and reliably. The conference also endorsed the classification of KP for vitiligo as proposed by the VETF (history based, clinical observation based, or experimentally induced). Lastly, the conference agreed that 'autoimmune vitiligo' should not be used as a separate classification as published evidence indicates that the pathophysiology of all forms of vitiligo likely involves autoimmune or inflammatory mechanisms.

Repigmentation of leucotrichia in vitiligo with noncultured cellular grafting.

BACKGROUND: Vitiligo in hair-bearing areas is often associated with leucotrichia. Repigmentation of leucotrichia has been reported mainly with tissue and follicular hair grafts. OBJECTIVES: To evaluate the repigmentation response of leucotrichia after noncultured cellular grafting. METHODS: We retrospectively reviewed patients with stable generalized and segmental vitiligo who underwent noncultured cellular grafting from March 2008 to November 2010 in areas with leucotrichia. The percentage repigmentation of white hairs was based on clinical assessment and standardized digital photography, and was graded 'poor', 'fair', 'good' or 'excellent', corresponding to a scale of 0-100% repigmentation with respective intervals of 25%. RESULTS: Eighty-four patients with vitiligo underwent cellular grafting; of these, 13 had grafting in areas with leucotrichia. Twelve patients (92%) had poor repigmentation of leucotrichia 3 months after transplant. One patient defaulted follow-up after this period. At 6months, fair repigmentation was achieved in eight out of the 12 remaining patients (67%). After 9-12months, however, 91% (10 out of 11) of the patients achieved good or excellent repigmentation. One patient did not reach the 9-month follow-up period at the time of data analysis. Leucotrichia of eyebrows yielded excellent repigmentation in eight out of nine patients, whereas hairs on the limbs and scalp showed good repigmentation in two out of two patients at 9-12 months. CONCLUSIONS: Good to excellent repigmentation of leucotrichia can be achieved with noncultured cellular grafting, obviating the need for hair transplantation.

Bilateral native ureteral ligation without nephrectomy in the management of kidney transplant recipients with native proteinuria.

The aim of this study was to assess the safety of bilateral native ureteral ligation (BNUL) without nephrectomy in the management of native proteinuria in kidney transplant (KTx) recipients. We retrospectively studied 17 patients who underwent BNUL between 2002 and 2010 with a median preoperative 24 h protein concentration of 2140 (range 1020-25 000) mg/L. Fifteen of the 17 patients had focal segmental glomerulosclerosis as their primary renal disease and ligation was employed to facilitate the diagnosis of early recurrence. The BNUL was performed simultaneously with KTx in 14 patients. Surgical techniques were: open (n = 5), pure laparoscopic (n = 1) and a hybrid of hand-assisted laparoscopic surgical/open approach (n = 12) used at the time of transplantation via the transplant incision. At a median follow-up of 46 months (range 1-59), no patient had a complication related to BNUL and none required interventions associated with their native kidneys. BNUL without nephrectomy seems to be a safe technique to manage native proteinuria in renal transplant candidates.

Long-term results of noncultured epidermal cellular grafting in vitiligo, halo naevi, piebaldism and naevus depigmentosus.

BACKGROUND: Several surgical techniques are available for the treatment of stable leucoderma. The use of noncultured epidermal cellular grafting was introduced in 1992. Data on long-term follow-up regarding stability of the repigmented area, time to achieve the final repigmentation, colour matching, reaction to sun exposure and patient satisfaction with treatment have been reported only a few times previously. OBJECTIVES: To evaluate the long-term results of the noncultured epidermal cellular grafting technique in patients with different types of leucoderma, including segmental vitiligo (n = 33), generalized vitiligo (n = 33), mixed vitiligo (n = 6), halo naevi (n = 11), piebaldism (n = 3) and naevus depigmentosus (n = 1). METHODS: Patients were evaluated by examination and questionnaire in a retrospective setting after transplantation by autologous noncultured cellular grafting. Percentage of repigmentation was evaluated in 82 patients using a digital imaging analysis system (mean follow-up 15 months). Long-term results were evaluated by 54 patients using a questionnaire up to 7·7 years after treatment (mean 4 years). RESULTS: More than 75% repigmentation was achieved in 71% of patients. Best results were obtained in segmental vitiligo, halo naevi and piebaldism, whereas results in generalized or mixed vitiligo were inferior. According to the patients, final repigmentation was achieved after a mean of 10 months post-treatment. In 80% some colour mismatch (hyperpigmentation and hypopigmentation) was reported between the treated area and the surrounding skin, although this was not disturbing for the majority. This colour mismatch was reported significantly less after sun exposure (P = 0·012). During follow-up 7% of patients, all with generalized vitiligo, observed some loss of the achieved repigmentation. CONCLUSIONS: Autologous epidermal cellular grafting achieved a high percentage of repigmentation, which was maintained during follow-up in the majority of patients. Although it improved quality of life, a perfect colour match was seldom obtained.

Prurigo pigmentosa: a report of two cases that responded to minocycline.

Prurigo pigmentosa (PP) is an unusual pruriginous dermatosis of unknown aetiology and is often misdiagnosed. We report two people (a 16-year-old Chinese boy and a 21-year-old Chinese woman), who presented with clinicopathological features consistent with PP. Both patients were successfully treated with minocycline. Better knowledge of this disease will lead to early recognition and appropriate treatment.

Is there a place for N.O.T.E.S. in the diagnosis and treatment of neoplastic lesions of the pancreas?

Natural orifice transluminal endoscopic surgery (NOTES) is the latest minimally invasive technique in the surgical armamentarium. Indeed it is stoking controversy already among both practitioners and patients, challenging established surgical, ethical and even moral principles. One organ which has been at the forefront of minimally invasive intervention is the pancreas. This review looks at the basis for evolving NOTES capabilities in the diagnosis and treatment of pancreatic diseases, with particular reference to neoplastic lesions and their complications. A summary of recent advancements in gastro-intestinal endoscopy and laparoscopic surgery as applied to the pancreas is presented. The possible role and feasibility of NOTES are outlined against this background.

A case of dermatopathia pigmentosa reticularis with wiry scalp hair and digital fibromatosis resulting from a recurrent KRT14 mutation.

We report a patient of Malay ancestry with dermatopathia pigmentosa reticularis (DPR) resulting from a recurrent KRT14 p.R125C mutation. The patient has reticulate hyperpigmentation over his trunk and proximal limbs, together with onychodystrophy. Despite the absence of noncicatricial alopecia, he has acral nonscarring blisters, palmoplantar hyperkeratosis and hypoplastic dermatoglyphics, in addition to unusual abnormalities such as wiry scalp hair and digital fibromatous thickening.

Spleen-preserving distal pancreatectomy.

INTRODUCTION: Splenectomy is routinely performed in conventional distal pancreatectomies. Spleen removal with its possible sequelae of infections and haematological complications has prompted the development of spleen-preserving techniques. This study aimed to evaluate the safety and clinical outcomes of distal pancreatectomy with preservation of the spleen. METHODS: A retrospective review of 24 consecutive patients who underwent spleen-preserving distal pancreatectomy in a tertiary care hospital was conducted. RESULTS: There were 17 female and seven male patients, and the mean age was 47 (range 14-77) years. Median American Society of Anesthesiologists score was II (range I-III) . The indications were as follows : mucinous cystadenoma (n = 7), serous cystadenoma (n = 6), insulinoma (n = 3), intraductal papillary mucinous tumour (n = 2), pseudocyst (n = 3), papillary cystic adenoma (n = 1), neuroendocrine neoplasm (n = 1), and metastatic carcinoma of the thyroid (n = 1). Two patients developed postoperative pancreatic fistula and another two patients developed postoperative ileus with spontaneous resolution. Mean operative time was 172 (range 105-250) minutes. Mean length of postoperative hospital stay was 6.7 (range 5-11) days. There was no perioperative mortality in this series. CONCLUSION: Spleen-preserving distal pancreatectomy can be safely performed with low morbidity, and should be considered in the surgical management of distal pancreatic disease.

Pathologic, radiologic and PET scan response of gastrointestinal stromal tumors after neoadjuvant treatment with imatinib mesylate.

AIM: The aim of this study is to review the radiologic, PET scan and pathologic response and the outcome of patients with advanced GIST treated with neoadjuvant IM followed by surgical resection. MATERIALS AND METHODS: We report a case and review 36 patients reported in MEDLINE with advanced GIST treated with neoadjuvant IM followed by surgical resection. RESULTS: Thirty-seven patients with a median age of 56 years (range, 32-76 years) at presentation were treated with neoadjuvant IM. Radiologic response accurately predicted pathological response in 31/36 patients, whereas PET scan was accurate in predicting treatment response in only 6/23 patients. CONCLUSION: This study demonstrates that the pathologic response of GIST to IM is usually incomplete and does not correlate with the complete response seen on PET scan. This finding suggests that surgical resection will continue to play a vital role in the treatment of patients with advanced disease responding to IM treatment.

Clinico-pathological features of cystic pancreatic endocrine neoplasms and a comparison with their solid counterparts.

AIM: Pancreatic endocrine neoplasms (PENs) may occasionally manifest as cystic lesions of the pancreas. The aim of this study is to report our experience with cystic PENs and to compare their clinico-pathological features with their solid counterparts. MATERIALS AND METHODS: From 1990 to 2004, 38 patients with PENs were reviewed. Six of these tumours appeared on radiological imaging as a cystic lesion of the pancreas. RESULTS: Of the 38 patients with a PEN, 21 of the patients were female and with a median age of 54.5 (range, 33-83) years. Sixteen patients had functional endocrine tumours of which insulinoma was the most common. The six patients with cystic PEN had a median age of 55.5 (range, 41-70) years and half were female. Cystic PENs were significantly larger [48 (range, 25-170) mm vs 19 (range, 3-120) mm, P = 0.013] and were less likely to be benign (0 vs 50%, P = 0.017) compared to their solid counterparts. There was no difference between cystic and solid PENs in terms of age, sex, presence of symptoms, proportion of functioning tumours and location of tumours within the pancreas. CONCLUSION: Cystic PENs share many clinico-pathological features with solid PENs. These differ only in the cystic appearance and tend to be of a larger size. Hence, these findings suggest that cystic and solid PENs are unlikely to be distinct pathological entities but are likely to be morphological variants of the same entity.