Evaluation of a laparoscopic liver resection in the setting of cirrhosis.

INTRODUCTION: Patients presenting with cirrhosis and hepatic tumours represent a fragile group that have typically been avoided in early series of laparoscopic liver resection. This study was undertaken to evaluate the results of a laparoscopic hepatectomy in the setting of cirrhosis. METHODS: Subgroup analysis of patients with cirrhosis within a series of 327 patients undergoing a laparoscopic resection was performed. Comparisons were made with patients without cirrhosis where appropriate to highlight differences in patient selection and outcomes. Specific variables assessed included operative details and short-term outcomes including length of stay (LOS), morbidity and mortality. Outcomes specific to hepatocellular carcinoma (HCC) were also assessed. RESULTS: There were 52 patients with cirrhosis undergoing a laparoscopic hepatic resection. Ninety per cent of patients were Childs class A, with a median model for end-stage liver disease (MELD) score of 8. Hepatitis C was the most common cause of cirrhosis (88.5%), whereas the most common indication for an operation was HCC (71.2%). Resections were generally limited, with the median number of segments resected being 2 (range: 1-4). Complications occurred in 13 (25%) patients, with a 90-day mortality of 5.8%. The median LOS was 3 days. CONCLUSIONS: A laparoscopic hepatectomy is safe in the setting of cirrhosis, provided the application of appropriate selection criteria and sufficient experience with the procedure.

Thyroid storm complicated by fulminant hepatic failure: case report and literature review.

OBJECTIVES: Thyroid storm is a presentation of severe thyrotoxicosis that has a mortality rate of up to 20% to 30%. Fulminant hepatic failure (FHF) entails encephalopathy with severe coagulopathy in the setting of liver disease. It carries a high mortality rate, with an approximately 60% rate of overall survival for patients who undergo orthotopic liver transplantation (OLT). Fulminant hepatic failure is a rare but serious complication of thyroid storm. There have been only 6 previously reported cases of FHF with thyroid storm. METHODS: We present a patient from our institution with thyroid storm and FHF. A literature review was performed to analyze the outcomes of the 6 additional cases of concomitant thyroid storm and FHF. RESULTS: Our patient underwent thyroidectomy followed by OLT. Her serum levels of thyroid-stimulating hormone, triiodothyronine, thyroxine, and transaminase normalized, and she was ready for discharge within 10 days of surgery. She has survived without complication. There is a 40% mortality rate for the reported patients treated medically with these conditions. Of the 7 total cases of reported FHF and thyroid storm, 2 patients died. Only 2 of the 7 patients underwent thyroidectomy and OLT--both at our institution. Both patients survived without complications. CONCLUSIONS: Thyroid storm and FHF each independently carry high mortality rates, and managing patients with both conditions simultaneously is an extraordinary challenge. These cases should compel clinicians to investigate liver function in hyperthyroid patients and to be wary of its rapid decline in patients who present in thyroid storm with symptoms of liver dysfunction. Patients with rapidly progressing thyroid storm and FHF should be considered for total thyroidectomy and OLT.

Robotic liver resection: initial experience with three-arm robotic and single-port robotic technique.

BACKGROUND AND OBJECTIVE: Robotic-assisted surgery offers a solution to fundamental limitations of conventional laparoscopic surgery, and its use is gaining wide popularity. However, the application of this technology has yet to be established in hepatic surgery. METHODS: A retrospective analysis of our prospectively collected liver surgery database was performed. Over a 6-month period, all consecutive patients who underwent robotic-assisted hepatic resection for a liver neoplasm were included. Demographics, operative time, and morbidity encountered were evaluated. RESULTS: A total of 7 robotic-assisted liver resections were performed, including 2 robotic-assisted single-port access liver resections with the da Vinci-Si Surgical System (Intuitive Surgical Sunnyvalle, Calif.) USA. The mean age was 44.6 years (range, 21-68 years); there were 5 male and 2 female patients. The mean operative time (± SD) was 61.4 ± 26.7 minutes; the mean operative console time (± SD) was 38.2 ± 23 minutes. No conversions were required. The mean blood loss was 100.7 mL (range, 10-200 mL). The mean hospital stay (± SD) was 2 ± 0.4 days. No postoperative morbidity related to the procedure or death was encountered. CONCLUSION: Our initial experience with robotic liver resection confirms that this technique is both feasible and safe. Robotic-assisted technology appears to improve the precision and ergonomics of single-access surgery while preserving the known benefits of laparoscopic surgery, including cosmesis, minimal morbidity, and faster recovery.

Evaluation of stapler hepatectomy during a laparoscopic liver resection.

METHODS: An international database of 1499 laparoscopic liver resections was analysed using multivariate and Kaplan-Meier analysis. RESULTS: In total, 764 stapler hepatectomies (SH) were compared with 735 electrosurgical resections (ER). SH was employed in larger tumours (4.5 versus 3.8 cm; P < 0.003) with decreased operative times (2.6 versus 3.1 h; P < 0.001), blood loss (100 versus 200 cc; P < 0.001) and length of stay (3.0 versus 7.0 days; P < 0.001). SH incurred a trend towards higher complications (16% versus 13%; P = 0.057) including bile leaks (26/764, 3.4% versus 16/735, 2.2%: P = 0.091). To address group homogeneity, a subset analysis of lobar resections confirmed the benefits of SH. Kaplan-Meier analysis in non-cirrhotic and cirrhotic patients confirmed equivalent patient (P = 0.290 and 0.118) and disease-free survival (P = 0.120 and 0.268). Multivariate analysis confirmed the parenchymal transection technique did not increase the risk of cancer recurrence, whereas tumour size, the presence of cirrhosis and concomitant operations did. CONCLUSIONS: A SH provides several advantages including: diminished blood loss, transfusion requirements and shorter operative times. In spite of the smaller surgical margins in the SH group, equivalent recurrence and survival rates were observed when matched for parenchyma and extent of resection.

Gastrinoma With Relatively Low Gastrin Levels: A Case Report.

Gastrinomas can often be cured with surgical removal if detected early enough. We present a case report where a patient was diagnosed with gastrinoma with relatively low serum gastrin levels after subsequent duodenojejunostomy, gastrojejunostomy, total gastrectomy, and cholecystectomy. With this case report, we hope to promote a higher level of awareness of pancreatic neuroendocrine (NE) tumors and educate clinicians on the full effects of proton pump inhibitor (PPI) use on patient workup, diagnostics, and care.

Prospective validation of quantitative polymerase chain reaction for management of cytomegalovirus disease in solid-organ transplant patients.

This study evaluates the utility of quantitative polymerase chain reaction (QPCR) to determine duration of treatment of transplant patients with human cytomegalovirus (HCMV) disease. Eighteen patients with HCMV disease were prospectively evaluated and followed for recurrence using a QPCR assay. We used plasma samples from which nucleic acid was extracted. Quantification was determined by using an internal standard that contained the same primer sequences as for HCMV. During treatment, weekly QPCR assays were performed. Patients were treated with HCMV immunoglobulin-G for a finite period, but intravenous ganciclovir was continued until less than 100 viral copies (vc) per mL was detectable. After cessation of therapy, patients were followed for 6 months with monthly clinical assessment and QPCR. No patient developed recurrence of HCMV at a mean follow-up of 16 months. This preliminary study suggests that the use of QPCR to assess viral load is useful in deciding the length of HCMV treatment with ganciclovir but requires further randomized validation.

Cutaneous Metastases from Primary Hepatobiliary Tumors as the First Sign of Tumor Recurrence following Liver Transplantation.

Cutaneous metastasis from hepatobiliary tumors is a rare event, especially following liver transplantation. We report our experience with two cases of cutaneous metastases from both hepatocellular carcinoma and mixed hepatocellular/cholangiocarcinoma following liver transplantation, along with a review of the literature.

Outcomes of laparoscopic and open resection for neuroendocrine liver metastases.

BACKGROUND: We sought to compare the outcomes in patients with hepatic carcinoid tumor metastases treated with open versus laparoscopic liver resection. METHODS: A retrospective analysis of our liver surgery database was performed. All patients who underwent liver resection for hepatic carcinoid tumor metastases were included. Patients were divided into 2 groups depending on the surgical approach. Patients with concomitant primary and metastatic liver lesions underwent open resection. RESULTS: Thirty-six patients underwent resection over a 10-year period (21 open and 15 laparoscopic). Both groups were similar in terms of gender, body mass index, tumor size, incidence of carcinoid syndrome, and extent of resection (P > .05). The laparoscopic group had less mean operative time (2.7 vs 5.4 hours), less mean blood loss (158.3 vs 538.9 mL), and a shorter hospital stay (3.2 vs 7.5 days; P < .05 for all). Complications were similar in both groups (20% vs 33%; P = .21). Two laparoscopic cases required conversion. The 3-year disease-free survival for the laparoscopic group was 73.3% compared to 47.6% for the open group (P = .2). CONCLUSION: To our knowledge, this is the first reported study comparing laparoscopic versus open liver resection in the treatment of liver metastases from carcinoid tumors. Our series confirms that selective cases can safely be managed laparoscopically.

Racial disparity and their impact on hepatocellular cancer outcomes in inner-city New Orleans.

BACKGROUND: The role of socioeconomic factors that affect survival, particularly for hepatocellular cancer (HCC), has yet to be fully analyzed. This study attempts to elucidate those racial and socioeconomic factors that affect differences in survival for patients with HCC. METHODS: In a retrospective cohort study of 206 patients with HCC diagnosed in an inner-city urban center from 2003 to 2011, outcomes by race (African Americans versus white) were analyzed. Additional attention was paid to socioeconomic factors. Continuous variables were compared with the Student t-test, and categorical variables were compared with the χ(2) or Fisher exact test. Multivariate analysis was conducted using a logistic regression model. Patient death and survival data were analyzed with Kaplan-Meier and Cox proportional hazards. RESULTS: Comparison of 138 white and 68 African-American patients revealed that African-American patients were more likely to present with larger tumor size at the time of diagnosis (4.7 vs 3.7 cm; P < .05). African-American patients were also more likely to be intravenous drug users (25.4% vs 11.6%; P < .05) and have cirrhosis from hepatitis C (81% vs 60%; P < .01). African-American patients were less likely to have private insurance compared with white patients (68% vs 92%; P < .01). Despite these findings in our inner-city practice, there was no difference in liver transplantation rates or survival rates between the 2 groups. CONCLUSION: Despite presentation with less-favorable tumor characteristics, African-American patients are able to achieve survival that is comparable with their white counterparts when treated in a program that is attuned to the challenges faced by their specific population.

Kidney transplantation alone in ESRD patients with hepatitis C cirrhosis.

BACKGROUND: Kidney transplantation (KTx) alone in patients with cirrhosis and renal failure (end-stage renal disease [ESRD]) infected with hepatitis C virus (HCV) is controversial. The aim of this study was to compare outcomes of HCV+ patients with ESRD and cirrhosis (C group) versus HCV+ patients with ESRD but with no cirrhosis (NC group) listed for KTx. METHODS: Ninety HCV+ patients with ESRD were evaluated for KTx between 2003 and 2010. Listed patients underwent transjugular liver biopsy with hepatic portal venous gradient (HPVG) measurements. Only patients with HPVG less than 10 mm Hg were considered for KTx alone. We analyzed patient demographics, waitlist/liver disease characteristics, and posttransplant outcomes between groups. RESULTS: Sixty-four patients listed for KTx alone were studied. Twelve patients (18.75%) showed biopsy-proven cirrhosis. Thirty-seven patients underwent KTx alone (9 from C and 28 from NC). No patients developed decompensation of their liver disease, although one patient for NC group developed metastatic hepatocellular carcinoma 16 months after transplantation. One- and three-year graft survival rates were 75% and 75% versus 92.1% and 75.1% for groups C and NC, respectively (P=0.72). One- and three-year patient survival rates were 88.9% and 88.9% versus 96.3% and 77.9% for groups C and NC, respectively (P=0.76). Only increasing recipient age and decreasing albumin levels were significantly associated with worse graft and patient survival. CONCLUSIONS: Our study suggests that KTx alone may be safe in patients with compensated HCV, cirrhosis, and ESRD with HPVG less than 10 mm Hg. A simultaneous liver-kidney transplantation may be an unnecessary use of a liver allograft in these patients.

Surgical advances in liver and bowel transplantation.

Liver and intestinal transplantation are currently the treatments of choice for life-threatening hepatic and gastrointestinal failure. These technologies have evolved through contributions from the fields of immunology, anatomy, physiology, surgery, anesthesiology, critical care, ethics, epidemiology, and public health. Transplantation now accounts for the treatment of over 5,000 recipients per year who are in a state of organ failure. The available donor population, however, is not increasing to meet the demands of the faster growing recipient population. This discrepancy has led to the rapid development of novel strategies that require critical evaluation to build on the success rates in recent years. This article presents the most salient advances in liver and intestinal transplantation in the last 15 years.

Multivisceral and isolated intestinal procurement techniques.

Improved outcomes in multivisceral and isolated intestinal transplantation have generated increased demand for these procedures. Enhanced recognition of potential multivisceral/intestinal donors and widespread application of advanced organ procurement techniques is necessary in the current climate of organ scarcity. This manuscript details the multivisceral and isolated intestinal procurement techniques currently performed at the University of California Los Angeles.

Fulminant liver failure due to usnic acid for weight loss.

The use of complementary and alternative medicine (CAM) in developed countries has increased significantly over the years. Among the most popular are the weight loss supplements or "fat burners." Liver failure due to these popular remedies has been widely recognized. Usnic acid has been an ingredient of dietary supplements that cause liver failure. Its hepatotoxicity has not been recognized because it is usually mixed with other ingredients that are presumably hepatotoxic. We describe a case of a 28-yr-old woman who presented with fulminant liver failure requiring orthotopic liver transplantation, after taking pure usnic acid for weight loss. This is the first report on fulminant liver failure associated with the ingestion of pure usnic acid. A discussion about hepatotoxicity of the different compounds of dietary supplements is presented. This is a reminder for the clinicians about the potential side effects of CAM.