Survival outcomes of surgical resection in perihilar cholangiocarcinoma in endemic area of O. Viverrini, Northeast Thailand.

BACKGROUND: Perihilar cholangiocarcinoma (pCCA) is an intractable malignancy and remains the most challenge for surgeon. This study aims to investigate survival outcomes and prognostic factors in pCCA patient. METHODS: From October 2013 to December 2018, 240 consecutive patients with pCCA underwent surgical exploration were retrospectively reviewed. The clinicopathological parameters and surgical outcomes were extracted. Patients were divided into two groups: unresectable and resectable group. The restricted mean survival time between two groups were analyzed. Factors associated with overall survival in resectable group were explored with multivariable Cox regression analysis. RESULTS: Of the 240 patients, 201 (83.75%) were received surgical resection. The survival outcomes of resectable group were better than unresectable group significantly. The restricted mean survival time difference were 0.5 (95%CI 0.22-0.82) months, 1.8 (95%CI 1.15-2.49) months, 4.7 (95%CI 3.58-5.87) months, and 9.1 (95%CI 7.40-10.78) months at four landmark time points of 3, 6, 12 and 24 months, respectively. The incidence of major complications and 90-day mortality in resectable group were 35.82% and 11.44%, respectively. Multivariable analysis revealed that Bismuth type IV (HR:4.43, 95%CI 1.85-10.59), positive resection margin (HR:4.24, 95%CI 1.74-10.34), and lymph node metastasis (HR:2.29, 95%CI 1.04-4.99) were all independent predictors of long-term survival. For pM0, R0 and pN0 patients, the median survival time was better than pM0, R1 or pN1/2 patients and pM0, R1 and pN1/2 patients (32.4, 10.4 and 4.9 months, respectively; p < 0.001) CONCLUSION: Surgical resection increased survival in pCCA. Bismuth type IV, positive resection margin and lymph node metastasis were independent factors for long-term survival.

Adenocarcinoma in Intraductal Tubulopapillary Neoplasm of the Pancreas: A Case Report and Literature Review.

Intraductal tubulopapillary neoplasms (ITPNs) are a subgroup of pre-malignant pancreatic epithelial lesions. The histomorphological and immunophenotypical characteristics of ITPN have been described by several authors based on case series; however, the rarity of this tumor subtype and its similarity to other entities makes the identification of ITPN challenging for radiologists and pathologists. Herein, we report a case of ITPN with associated invasive carcinoma along with a literature review that will benefit further studies and help in planning treatments for patients in the future. A pancreatic mass was incidentally discovered in a 40-year-old woman during her annual check-up. Radiological investigation revealed a mass that obstructed the main pancreatic duct and caused ductal dilatation. Endoscopic retrograde cholangiopancreatography with biopsy indicated poorly differentiated adenocarcinoma. Subsequently, total pancreatectomy with splenectomy was performed to remove the tumor. ITPN of the pancreas with associated poorly differentiated adenocarcinoma was diagnosed based on pathological and immunohistological test results. Achieving complete resection of the tumor, the patient did not require chemotherapy during follow-up care. Thus, our study demonstrated the necessity of radiological and histopathological correlation in the definitive diagnosis of pancreatic ITPN. However, the determination of an invasive component is essential because malignant transformation affects the prognosis of patients.

Pure Laparoscopic Donor Right Hepatectomy for Rare Non-Bifurcation Portal Vein Variation Donor and Reconstruction Technique.

BACKGROUND: Pure laparoscopic donor right hepatectomy (PLDRH) is a technical demanding procedure, and many centers have strict selection criteria especially an anatomical variation. Portal vein variation is considered as a contra-indication for this procedure in most centers. We presented a case of PLDRH in donor who had rare non-bifurcation portal vain variation. The donor was 45-year-old female. Pre-operative imaging showed a rare non-bifurcation portal vain variation. The procedure was following the routine step of laparoscopic donor right hepatectomy except the hilar dissection phase. All portal branches should not be dissected before division of bile duct to prevent vascular injury. Regarding bench surgery, all portal branches were reconstructed together. Finally, the explanted portal vein bifurcation was used to reconstruct all portal vein branches as a single orifice. The liver graft was successfully transplanted. The graft was well functioned, and all portal branches were patented. CONCLUSION: This technique facilitated identification and safely divided all portal branches. PLDRH in donor with this rare portal vein variation can be performed safely by a highly experienced team and good reconstruction technique. Pure laparoscopic donor right hepatectomy (PLDRH) is a technical demanding procedure, and many centers have strict selection criteria especially an anatomical variation. Portal vein variation is considered as a contra-indication for this procedure in most centers. Lapisatepun and colleagues report PLDRH in rare non-bifurcation portal vein variation, and reconstruction technique was scanty reported.

A Rare Case of Primary Adrenal Epithelioid Angiosarcoma.

BACKGROUND Primary adrenal epithelioid angiosarcoma (PAEA) is a very uncommon primary adrenal gland tumor that usually occurs around the age of 60 years and is more common among males. Owing to its rarity and histopathological features, PAEA could be misdiagnosed as adrenal cortical adenoma, adrenal cortical carcinoma, or other metastatic cancers, such as metastatic malignant melanoma and epithelioid hemangioendothelioma. CASE REPORT A 59-year-old male patient presented to our hospital with a complaint of abdominal bloating that started 2 months prior. His vital signs and the results of his physical and neurological examinations were unremarkable. A computed tomography scan showed a lobulated mass arising from the hepatic limb of the right adrenal gland but no evidence of metastasis to the chest or abdomen. The patient underwent right adrenalectomy, and the macroscopic pathological findings from a right adrenalectomy specimen revealed atypical tumor cells with an epithelioid appearance in the background of an adrenal cortical adenoma. Immunohistochemical staining was performed to confirm the diagnosis. The final diagnosis was epithelioid angiosarcoma involving the right adrenal gland with a background adrenal cortical adenoma. The patient had no postoperative complications, pain in the surgical wound, or fever. Therefore, he was discharged with a schedule for followup appointments. CONCLUSIONS PAEA may be misinterpreted as adrenal cortical carcinoma, metastatic carcinoma, or malignant melanoma radiologically and histologically. Immunohistochemical stains are essential for diagnosing PAEA. Surgery and strict monitoring are the main treatments. In addition, early diagnosis is essential for patient recovery.

Development of clinical prediction rule for the requirement of endoscopic papillary large balloon dilation (EPLBD) on endoscopic CBD stone clearance.

INTRODUCTION: To develop a simplified scoring system for clinical prediction of difficulty in CBD stone removal to assist endoscopists working in resource-limited settings in deciding whether to proceed with an intervention or refer patients to a center capable of performing additional procedures and interventions. METHODS: This study included patients with CBD stones who underwent ERCP at Pattani Hospital between August 2017 and December 2021. Retrospective cohort data was collected and patients were categorized into two groups: bile duct stones successfully treated by endoscopic biliary sphincterotomy and extraction compared to the former method combined with EPLBD. We explored potential predictors using multivariable logistic regression. The chosen logistic coefficients were transformed into a scoring system based on risk with internal validation via bootstrapping procedure. RESULTS: Among the 155 patients who had successful endoscopic therapy for bile duct stones, there were 79 (50.97%) cases of endoscopic biliary sphincterotomy, EPLBD and extraction versus 76 (49.03%) cases without EPLBD. The factors used to derive a scoring system included the size of CBD stones >15 mm, the difference between the stone and distal CBD diameter >2mm, distal CBD arm length <36 mm and stone shape. The score-based model's area under ROC was 0.88 (95% CI: 0.83, 0.93). For clinical use, the range of scores from 0 to 16, was divided into two subcategories based on CBD stone removal difficulty requiring EPLBD to derive the PPV. For scores <5 and ≥ 5, the PPV was 23.40 (p <0.001) and 93.44 (p <0.001) respectively. The Bootstrap sampling method indicated a prediction ability of 0.88 (AuROC, 95% CI: 0.83, 0.94). CONCLUSION: This scoring system has acceptable prediction performance in assisting endoscopists in their choice of stone removal procedure.

Outcomes of the Initial Phase of an Adult Living vs Deceased Donor Liver Transplantation Program in a Low-Volume Transplant Center: Integration of Hepatobiliary and Transplant Surgery.

BACKGROUND: The development of living donor liver transplantation (LDLT) is clinically challenging, especially in a low-volume transplant program. We evaluated the short-term outcomes of LDLT and deceased donor liver transplantation (DDLT) to demonstrate the feasibility of performing LDLT in a low-volume transplant and/or high-volume complex hepatobiliary surgery program during the initial phase. MATERIAL AND METHODS: We conducted a retrospective study of LDLT and DDLT in Chiang Mai University Hospital from October 2014 to April 2020. Postoperative complications and 1-year survival were compared between the 2 groups. RESULTS: Forty patients who underwent LT in our hospital were analyzed. There were 20 LDLT patients and 20 DDLT patients. The operative time and hospital stay were significantly longer in the LDLT group than in the DDLT group. The incidence of complications in both groups was comparable, except for biliary complications, which were higher in the LDLT group. Bile leakage, found in 3 patients (15%), is the most common complication in a donor. The 1-year survival rates of both groups were also comparable. CONCLUSION: Even during the initial phase of the low-volume transplant program, LDLT and DDLT had comparable perioperative outcomes. Surgical expertise in complex hepatobiliary surgery is necessary to facilitate effective LDLT, potentially increasing case volumes and promoting program sustainability.

Common bile duct stone-related parameters and their potential prognostic values for stone extraction requiring endoscopic papillary large balloon dilation.

Background and Aim: For difficult common bile duct (CBD) stones, endoscopic sphincterotomy accompanied by endoscopic papillary large balloon dilatation (EPLBD) may be the preferred initial procedure according to the selection criteria. The purpose of this study was to determine the association between CBD stone-related parameters and their potential prognostic values for technically difficult CBD stone extraction requiring EPLBD. Methods: We retrospectively analyzed the data of 80 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), endoscopic biliary sphincterotomy, or the aforementioned procedures combined with EPLBD, resulting in successful CBD stone extraction in the first session from January 2018 and December 2021. The association between CBD stone-related parameters and stone extraction requiring EPLBD was analyzed by multivariable risk regression analysis. Results: In multivariable analysis, the independent predictors of CBD stone extraction that required EPLBD were CBD stones larger than distal CBD diameter by >2 mm (risk ratio [RR] 2.34, 95% CI 1.30-4.19) and the presence of shaped stones (round shape RR 1.69 [95% CI 1.05-2.73]; square shape RR 2.34 [95% CI 1.24, 4.44] vs oval shape). Conclusion: Endoscopic CBD stone removal is technically difficult in patients with stones larger than 2 mm in diameter in comparison to the distal CBD diameter or round or square-shaped stones.

Efficacy of intravenous versus intraperitoneal lidocaine for postoperative analgesia in laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the gold standard for gallbladder removal due to the low degree of invasiveness. However, postoperative pain still persists. Local anesthetics provide analgesia, reduce opioid consumption, and accelerate the return of bowel activity with a rare incidence of toxicity. However, it is still inconclusive to verify the more superior route of administration. This study aimed to compare the efficacy of intravenous lidocaine infusion, intraperitoneal lidocaine instillation, and placebo in reducing postoperative analgesia. METHODS: In this prospective, randomized, double-blind, placebo-controlled trial, the participants were randomized into three groups; intravenous lidocaine infusion (IV group), intraperitoneal lidocaine instillation (IP group), and control. The primary outcome was opioid consumption and secondary outcomes were side effects and recovery profiles. RESULTS: Opioid consumption at 2, 4, and 6 postoperative hours was statistically lower in IV group compared to the IP and control group (P<0.05). VAS for abdominal pain (VAS(abd) at 6, 12, and 24 hours were reduced in both IV and IP groups compared to the control group. However, VAS at incision site (VAS(inc) were not different amongst all three groups. Number of patients who met the discharge criteria within six hours after surgery was significantly higher in the IV group (P=0.028). CONCLUSIONS: Intravenous lidocaine is superior to intraperitoneal lidocaine instillation and placebo in reducing postoperative analgesic requirement and visceral pain within the first six hours. Intravenous infusion is a simple and reliable method for reducing abdominal pain following laparoscopic cholecystectomy.

Comparative outcomes of pure laparoscopic and open donor right hepatectomy: the first report from a Southeast Asian transplant center.

BACKGROUND: Pure laparoscopic donor right hepatectomy (PLDRH) can provide better operative outcomes for the donor than conventional open donor right hepatectomy (CODRH). However, the complexity of the procedure typically makes transplant teams reluctant to perform it, especially in low-volume transplant centers. We compared the outcomes of PLDRH and CODRH to demonstrate the feasibility of PLDRH in a low-volume transplant program. METHODS: We carried out a retrospective study of adult living donor liver transplantation in Chiang Mai University Hospital from January 2015 to March 2021. The patients were divided into a PLDRH group and a CODRH group. Baseline characteristics, operative parameters, and postoperative complications of donors and recipients were compared between the two groups. RESULTS: Thirty patients underwent donor hepatectomy between the dates selected (9 PLDRH patients and 21 CODRH patients). The baseline characteristics of the 2 groups were not significantly different. The median graft volume of the PLDRH group was 693.8 mL, which was not significantly different from that of the CODRH group (726.5 mL) The PLDRH group had a longer operative time than the CODRH group, but the difference was not statistically significant (487.5 min vs 425.0 min, p = 0.197). The overall complication rate was not significantly different between the two groups (33.3% vs 22.2%, p = 0.555). Additionally, for the recipients, the incidence of major complications was not significantly different between the groups (71.3 vs 55.6%, p = 0.792). CONCLUSION: Even in the context of this low-volume transplant program, whose staff have a high level of experience in minimally invasive hepatobiliary surgery, PLDRH showed similar results to CODRH in terms of perioperative outcomes for donors and recipients.

Higher cumulative fluid following a pancreaticoduodenectomy as a single modifiable factor for post-operative pancreatic fistula: An analysis of risk factor.

BACKGROUND: Postoperative pancreatic fistula (POPF) is one of the major complications after pancreaticoduodenectomy. There have been many studies into the risk factors determining POPF. Some studies have reported a higher peri-operative fluid balance associated with POPF, however, the pertinent findings remain controversial. The aims of this study were to determine risk factors of clinically relevant-post operative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy and an association between peri-operative fluid balance and the incidence of CR-POPF. MATERIALS AND METHODS: This is a retrospective cohort study included all adult patients who underwent an elective open pancreaticoduodenectomy in our center from 2005 to 2018. Patients who did not have POPF related data were excluded from study. We divided patients into CR-POPF and no CR-POPF group. Peri-operative data including amount and type of fluid were compared between two groups. Logistic regression analysis was used to identify the independent risk factors of CR-POPF. RESULTS: There were 223 pancreaticoduodenectomies done in our center during that period. The incidence of CR-POPF was 15.2 %. Patients in CR-POPF group had significant higher BMI, higher serum globulin level, smaller pancreatic duct diameter and higher cumulative fluid balance per body weight (FBPBW) at post-operative day 3. Multivariable analysis showed BMI >23 kg/m2, diagnosis other than pancreatic duct adenocarcinoma or chronic pancreatitis and higher cumulative FBPBW at post-operative day 3 were the independent risk factors for CR-POPF. CONCLUSIONS: Post-operative fluid balance was the post-operative modifiable risk factor to reduce CR-POPF. Higher positive post-operative fluid balance should be avoided especially in higher CR-POPF risk patients.

Effect of Recombinant Human Erythroferrone Protein on Hepcidin Gene (Hamp1) Expression in HepG2 and HuH7 Cells.

Iron is essential for all living organisms. It is strictly controlled by iron transporters, transferrin receptors, ferroportin and hepcidin. Erythroferrone (ERFE) is an iron-regulatory hormone which is highly expressed in erythroblasts by erythropoietin (EPO) stimulation and osteoblasts independently of EPO by sequestering bone morphogenetic proteins and inhibiting hepatic hepcidin expression. Although the hepcidin suppressive function of ERFE is known, its receptors still require investigation. Here, we aim to identify ERFE receptors on the HepG2 and Huh7 cells responsible for ERFE. Recombinant ERFE (rERFE) was first produced in HEK293 cells transfected with pcDNA3.1 + ERFE, then purified and detected by Western blot. The liver cells were treated with an rERFE-rich medium of transfected HEK293 cells and a purified rERFE-supplemented medium at various time points, and hepcidin gene (Hamp1) expression was determined using qRT-PCR. The results show that 37-kD rERFE was expressed in HEK293 cells. Hamp1 was suppressed at 3 h and 6 h in Huh7 cells after rERFE treatments (p < 0.05), then restored to the original levels. Hamp1 was activated after treatment with purified rERFE for 24 h and 48 h. Together, these results reveal that ERFE suppressed Hamp1 expression in liver cells, possibly acting on membrane ERFE receptor, which in Huh7 cells was more sensitive to the ERFE concentrate.

Efficacy and safety of infrahepatic inferior vena cava clamping under controlled central venous pressure for reducing blood loss during hepatectomy: A randomized controlled trial.

BACKGROUND: The purpose of this study was to evaluate the effectiveness and safety of inferior vena cava (IVC) clamping for reducing blood loss during hepatectomy. METHODS: In total, 120 elective hepatectomy patients who underwent surgery from May 2016 to October 2017 were enrolled and randomized into the IVC clamping group or nonclamping group. Both groups were managed by anesthesiological techniques for CVP reduction. Blood loss and clinical parameters were analyzed for 30 days after surgery. RESULTS: Fifty-nine patients were assigned to the IVC clamping group and 61 to the non-IVC clamping group. There was a significant difference in the total blood loss between both groups, with less blood loss observed in the IVC clamping group [500 vs 600 mL, P = .006]. The transection blood loss in the IVC clamping group was also significantly lower than that in the non-IVC clamping group [300 vs 500 mL, P < .001]. However, CVP was not associated with blood loss volume. Postoperative outcomes were not significant in either group. CONCLUSIONS: IVC clamping is beneficial for reducing blood loss during hepatectomy and is safe when combined with anesthesiological techniques. If feasible, this technique should be used regardless of the CVP value.

The benefit of curative liver resection with a selective bile duct preserving approach for hepatocellular carcinoma with macroscopic bile duct tumor thrombus.

BACKGROUND: Hepatocellular carcinoma (HCC) presenting with macroscopic bile duct tumor thrombus (BDTT) is an uncommon event. The role of a curative hepatic resection and associated long-term outcomes remain controversial. In addition the necessity for bile duct resection is still unclear. The aim of this study was to evaluate outcomes of hepatectomy with a selective bile duct preservation approach for HCC with BDTT in comparison to outcomes without BDTT. METHODS: A total of 22 HCC with BDTT patients who had undergone curative hepatic resection with a selective bile duct preservation approach at our institute were retrospectively reviewed. These were compared to group of 145 HCC without BDTT patients. The impact of curative surgical resection and BDTT on clinical outcomes and survival after surgical resection were analyzed. RESULTS: All HCC with BDTT cases underwent major hepatectomy vs. 32.4% in the comparative group. Bile duct preservation rate was 56.5%. The 1-, 3- and 5-year survival rates of HCC with BDTT patients in comparison to the HCC without BDTT group were 81.8%, 52.8% and 52.8% vs. 73.6%, 55.6% and 40.7% (P=0.804) respectively. Positive resection margin, tumor size ≥5 cm and AFP ≥200 IU/mL were significant risk factors regarding overall survival. However, it is unclear whether presence of a bile duct tumor thrombus has an adverse impact on either recurrence free survival or overall survival. CONCLUSIONS: Bile duct obstruction from tumor thrombus did not necessarily indicate an advanced form of disease. Tumor size and AFP had greater impact on long-term outcomes than bile duct tumor thrombus. Major liver resection with a selective bile duct preserving approach in HCC with BDTT can achieve favorable outcomes comparable to those of HCC without BDTT in selected patients.

Adult-to-Adult Living Donor Liver Transplantation: Postoperative Outcomes and Quality of Life in Liver Donors: First Report in Thailand.

BACKGROUND: Deceased donor liver transplantation is a rare procedure in Northern Thailand because of cultural issues. Living donor liver transplantation (LDLT) can decrease waiting list mortality for the patients who have end-stage liver disease. In Thailand, our center is the only active adult-to-adult LDLT program. This study is the first report of outcomes and health-related quality of life in liver donors. OBJECTIVES: The aim of this study was to evaluate the postoperative outcomes and health related quality of life in living liver transplant donors at the Transplant Center in Thailand. MATERIALS AND METHODS: All patients undergoing liver resection for adult-to-adult LDLT at our center between March 2010 and July 2018 were evaluated in a cross-sectional study. The effect of donor demographics, operative details, postoperative complications (Clavien-Dindo classification), hospitalization, and health related quality of life was evaluated through health-related quality of life questionnaires (short-form survey, SF-36) RESULTS: A total of 14 donor patients were included in this study with an age range from 26 to 51 years (mean 39.86 years, standard deviation [SD] = 8.59 years). The patients were 71.43% female and 28.57% male. The majority of patients had primary and secondary education (57.14%) and were married (64.29%). After hepatectomy, there was no mortality in the evaluated donors. The Clavien-Dindo classification of postoperative complications were as follows: Grade I (none), Grade II (50%), Grade IIIa (7.14%), and Grade IIIb (7.14%). The serum levels of total protein and albumin were decreased on postoperative day 5. The hospital stays averaged 11.5 days (SD = 4.9 days) and ranged from 5 to 22 days. After considering each aspect of the donors' postoperative quality of life, the highest mean score was related to physical composite scores in physical roles with a mean of 96.42 (SD = 13.36) and physical function with a mean of 95.35 (SD = 13.36). Moreover, the mental composite scores in social function was the highest mean of 91.96 (SD = 12.60) and role emotion was a mean of 90.47 (SD = 27.51). CONCLUSIONS: Living donor hepatectomy was safe, with an acceptable morbidity, and recognized as a safe procedure with an excellent long-term health quality of life.

Price to pay; Portal vein arterialization for hepatic artery thrombosis after living donor liver transplantation; A case report.

OBJECTIVE: Hepatic artery thrombosis (HAT) is one of the most serious complications of liver transplantation that can potentially lead to loss of the allograft. Retransplantation is the only option when revascularization can't be performed but the donor may be not available in the short period of time. We report the technique of using portal vein arterialization (PVA) for bridging before retransplantation. There are few reports in living donor setting. CASE DESCRIPTION: The recipient of the liver was a 59 year old male who received an extended right lobe graft from his son. Post operative day 41, HAT was diagnosed from angiogram and liver function got rapidly worse. We decided to re-anastomose the hepatic artery but this was not possible due to a thrombosis in the distal right hepatic artery. So PVA by anastomosis of the common hepatic artery to splenic vein was performed. During the early postoperative period liver function gradually improved. Unfortunately, he died from massive GI hemorrhage one month later. DISCUSSION: PVA has previously been reported as being useful when revascularization was not successful. The surgical technique is not complicated and can be performed in sick patient. Liver graft may be salvaged with oxygenated portal flow and recover afterwards. However, portal hypertension after PVA seem to be an inevitable complication. CONCLUSIONS: PVA may be a bridging treatment for retransplantation in patients whom hepatic artery reconstruction is impossible after HAT. Regards to the high morbidity after procedure, retransplantation should be performed as definite treatment as soon as possible.

Lacerated Liver Graft in an Open Abdomen Setting: A Case Report.

Donor scarcity is a primary problem in the development of a transplant program. The imbalance between an extremely increasing demand and the number of organs in the supply has led to an extended criteria donor approach. The successful use of donors with infectious diseases and septic shock has been reported. However, organs from deceased donors with traumatic abdominal injury and open abdomen are usually discarded due to risks of severe infections. Thus far, only 1 such case, in which a liver graft from an open abdomen was used successfully, has been reported. Herein, we report of a case of liver transplant using a traumatized liver allograft procured from a deceased donor with an open abdomen. The donor was a 16-year-old patient who had blunt abdominal trauma and severe head injury from a car accident, resulting in emergency laparotomy with suturing of the lacerated wound at the liver and abdominal packing. The donor was subsequently pronounced brain dead, and the family consented to organ donation. A multiorgan procurement was performed, and the liver was transplanted to 52-year-old patient who had multiple hepatocellular carcinomas. The postoperative course was without any infection or rejection. In conclusion, the use of donor livers with preexisting trauma in open abdomen settings can be used as alternative to expand the organ donor pool.

A single institution report of 19 hepatocellular carcinoma patients with bile duct tumor thrombus.

BACKGROUND: Obstructive jaundice caused due to bile duct tumor thrombus (BDTT) in a hepatocellular carcinoma (HCC) patient is an uncommon event. This study reports our clinical experiences and evaluates the outcomes of HCC patients with BDTT in a single institution. METHODS: A retrospective review of 19 HCC patients with secondary obstructive jaundice caused due to BDTT during a 15-year period was conducted. RESULTS: At the time of diagnosis, 14 (73.7%) patients had obstructive jaundice. Eighteen (94.7%) patients were preoperatively suspected of "obstruction of the bile duct". Sixteen patients (84.2%) underwent a hepatectomy with curative intent, while two patients underwent removal of BDTT combined with biliary decompression and another patient received only palliative care as his liver reserve and general condition could not tolerate the primary tumor resection. The overall early recurrence (within 1 year) after hepatectomy occurred in more than half (9/16, 56.3%) of our patients. The 1-year survival rate of patients was 75% (12/16). The longest disease-free survival time was >11 years. CONCLUSION: Identification of HCC patients with obstructive jaundice is clinically important because proper treatment can offer an opportunity for a cure and favorable long-term survival.

Prognostic Factors and Survival of Patients with Carcinoma of the Ampulla of Vater after Pancreaticoduodenectomy

Background: Although carcinoma of the ampulla of Vater (CAV) is a rare tumor, accounting for just 0.2% of gastrointestinal cancers, the survival of CAV patients is unfavorable. The five-year rates have ranged from 36.8-75.2% in previous reports but there is a lack of data relating to Thai people. Also prognostic factors are controversial. Objectives: This study aimed to determine survival outcomes and to identify prognostic factors for a positive outcome for CAV patients after surgery. Methods: In this retrospective cohort study, data were collected from CAV patients who underwent surgery in Chiang Mai University Hospital from 2005 to 2012 for time to event analysis, the log rank test and univariate and multivariate Cox's regression analysis. Results: There were 72 CAV patients recruited, 45.8% being male. The mean age was 65.1 ± 10.5 years and the median waiting time for surgery was 56.5 days (24.5-91.5). The 30 day mortality rate was 5.6%., while 5-yr survival was 33.3%. The average disease free survival was 14.6 months. Prognostic factors relating to recurrence were positive lymph nodes (50% VS 19.6% p = 0.015) and advanced stage (44.1% VS 18.4% p = 0.023). Multivariate analysis showed that the potential prognostic factors for CAV patients included recurrence, moderate and poor differentiation, comorbidities and a tumor size > 2.0 cm. Conclusions: The findings of the study indicate that the overall survival of CAV patients after surgery is quite fair, with a tendency for better outcome with early as compared to advanced lesions. The key prognostic factors were recurrence, moderate and poor differentiation, comorbidity and tumor size > 2.0 cm.