Cirrhotic and non-cirrhotic huge hepatocellular carcinoma (≥ 10 cm): a comparative study of surgical management and follow-up treatment in a single institution.

PURPOSE: Liver resection (LR) of huge hepatocellular carcinoma (HCC) has increasingly been regarded as a viable option of enhanced efficacy for patients, but most studies have focused on comparing various tumor sizes and the outcomes of surgery. The study aim was to evaluate the clinicopathologic characteristics and surgical outcomes of huge HCC with and without cirrhosis that underwent LR, and to delineate the treatment for recurrence. METHODS: Sixty-three patients with huge HCC who underwent hepatectomy from 2010 to 2019 were enrolled and reviewed. Clinicopathological findings, surgical outcomes of the entire cohort, and differences between the cirrhotic and non-cirrhotic groups were analyzed. RESULTS: Forty patients (60.3%) had huge HCC with cirrhosis. Clinicopathological findings were not different between the two groups, except tumor size ≥ 15 cm (40% in cirrhosis vs 17.4% in non-cirrhosis, p = 0.024) and major portal vein tumor thrombus were detected only in the cirrhosis group (11 patients, p = 0.006). Extended LR was performed in 13 cirrhotic patients (32.5%) and in 1 non-cirrhotic patient (4.4%) (p = 0.010). Operative data, postoperative complications including postoperative liver failure, and pattern of recurrence were not different between the two groups. For the entire cohort, mortality rate was 1.5%. The 1-, 3-, and 5-year overall survival rates (OS) were 81%, 54%, and 39%. Multivariate analysis showed resection margin ≥ 0.1 cm was a good prognostic factor for OS (HR 0.247 (p = 0.017)). For tumor recurrence, local ablative treatment for liver recurrence and resection for lung recurrence provided good long-term outcomes. CONCLUSION: Although huge HCC with cirrhosis has been a more unfavorable tumor, LR still provided long-term survival with acceptable risk morbidity and mortality.

Comparison of intrathecal morphine and low-dose bupivacaine with intravenous morphine for postoperative analgesia in laparoscopic liver resection: a randomized controlled trial.

BACKGROUND: Laparoscopic liver surgery has undergone substantial advancements over the past few decades, and the key to this improvement has been an improved understanding of liver anatomy, radiologic imaging, and advancements in anesthesia and postoperative care. This study aimed to compare postoperative opioid consumption in patients receiving intrathecal morphine plus low-dose bupivacaine versus those receiving intravenous morphine. METHODS: In this randomized controlled trial, 40 patients were enrolled and randomly assigned to two groups, of which one received 0.2 mg intrathecal morphine plus 0.25% Marcaine in a total volume of 4 mL and the other received intravenous morphine intraoperatively. Pain relief and patient satisfaction were evaluated using the visual analog scale. Intraoperative blood loss was measured at the end of the surgery while morphine consumption was measured by monitoring intravenous patient-controlled morphine at 12, 24, 36, and 48 h postoperatively. Treatment efficacy and complications were documented. RESULTS: Morphine consumption was significantly different in both groups at all time points, although the pain score did not show any difference. Shoulder pain, a common adverse effect of laparoscopic surgery, was significantly lower in the intrathecal group (25% vs. 75%). Blood loss and patient satisfaction were not different between the groups. However, the intrathecal group showed a significantly higher incidence of intraoperative hypotension. CONCLUSION: Intrathecal morphine with bupivacaine can be used effectively for managing acute post-LLR pain. THAI CLINICAL TRIAL REGISTRY: TCTR20211015004.

Comparison of Three Inferior Vena Cava Reconstruction Techniques in Adult Orthotopic Liver Transplantation: Result From King Chulalongkorn Memorial Hospital, Thailand.

BACKGROUND: In orthotopic liver transplantation (OLT), 3 caval reconstruction techniques are being performed worldwide. These are conventional, piggyback technique, and side-to-side cavocaval anastomosis (CCA). Each has its own advantages and drawbacks. Herein we report the result from our hospital comparing the 3 techniques. METHODS: We retrospectively reviewed the detail of OLT performed from January 2008 to March 2020. Data being collected included type of caval reconstruction, blood loss, operative time, ischemic time, length of stay in the intensive care unit (ICU) and total hospital stay, and several postoperative complications. RESULTS: In the given period, 11 conventional, 90 piggyback, and 113 CCA caval reconstruction were done. There were no statistically significant differences in blood loss, operative time, cold ischemic time, and length of ICU and hospital stay. The CCA group had the lowest warm ischemic time (40 minutes) followed by the piggyback technique (43 minutes) and the conventional technique (47 minutes; P < .001). Regarding postoperative complications, there were no statistically significant differences in rate of primary nonfunction, early allograft dysfunction, hepatic artery/portal vein/biliary complication, or rate of acute kidney injury. The hepatic venous outflow complication rate was indifferent between 3 groups. CONCLUSIONS: The present study showed no difference in outflow obstruction rate among the 3 techniques. The choice for reconstruction should rely on the preference of each institute and the suitability of each patient. The CCA technique may provide the lowest warm ischemic time.

Partial segments 4/5 liver resection facilitates the repair of complicated bile duct injuries: a technical challenge and long-term outcomes.

Adequate exposure with optimal anteroposterior view of the hilar plate is challenging and crucial in a surgical repair of complicated hilar bile duct injuries. A high-quality anastomosis depends on the ability to identify non-scarred, non-inflamed, non-ischemic bile ducts. This study provides operative details of the Partial Segments 4/5 Liver Resection with a Roux-en-Y hepaticojejunostomy (PS4/5LRHJ) and presents its long-term outcomes. 36 patients with the Strasberg type E bile duct injuries (BDIs) who underwent the PS4/5LRHJ from 2003 to 2019 were retrospectively reviewed. Outcomes of the surgical treatments were analyzed. The mean age of the patients was 46.3 years. 22 patients underwent BDI repair as index operations and 14 patients as re-repair operations. Operative times between the index operation group and the re-repair group (396.6 min vs 391.3 min, respectively, p = 0.876) and blood loss (590.6 ml vs 640 ml, respectively, p = 0.587) were not statistically different. The mean length of hospital stay was 23 days. The median follow-up duration was 73 months. Major complications developed in 10 patients (27.8%), of which intra-abdominal collection was the most common (eight patients, 22.2%). Anastomotic stricture developed in one patient (2.8%). The mortality rate was zero. The overall 10-year patency rate was 95.2%. PS4/5LRHJ offered long-term patency with acceptable morbidity in the hilar bile duct injuries and re-repair operations.

A randomized controlled trial of comparative effectiveness between the 2 dose and 3 dose regimens of hepatitis a vaccine in kidney transplant recipients.

Hepatitis A virus (HAV) is able to cause a spectrum of illnesses ranging from no symptom to fulminant hepatitis which may lead to acute kidney injury. Although hepatitis A vaccine is recommended in non-immune solid organ transplant recipients who live in or travel to endemic areas, the standard 2-dose vaccination regimen demonstrated less favorable immunogenicity among these population. The 3-dose regimen showed higher response rate and immune durability in patients with human immunodeficiency virus. However, this strategy has never been studied in solid organ transplant recipients. A single-center, open-labeled, computer-based randomized controlled trial (RCT) with a 2:1 allocation ratio was conducted from August 2017 to December 2018. The study compared the seroconversion rate after receiving 2- or 3-dose regimen of hepatitis A vaccine at 0, 6 and 0, 1, 6 months, respectively, in non-immune kidney transplant recipients. A total of 401 adult kidney transplant recipients were screened for anti-HAV IgG and 285 subjects had positive results so the seroprevalence was 71.1%. Of 116 seronegative recipients, 93 (80.2%) completed vaccination; 60 and 33 participants completed 2- and 3-dose vaccination, respectively. The baseline characteristics were comparable between both groups. The seroconversion rate at 1 month after vaccination was 51.7% in the standard 2-dose regimen and 48.5% in the 3-dose regimen (p = 0.769). Overall, the seroconversion rate appeared to be associated with high estimated glomerular infiltration rate, high serum albumin, and low intensity immunosuppressive regimen. Seroconversion rate after hepatitis A vaccination in kidney transplant recipients was less favorable than healthy population. Three-dose regimen did not show superior benefit over the standard 2-dose regimen. Other strategies of immunization may increase immunogenicity among kidney transplant recipients.

Benefits of simultaneous laparoscopic colorectal surgery and liver resection for colorectal cancer with synchronous liver metastases: Retrospective case-matched study.

INTRODUCTION: Laparoscopic surgery for colorectal cancer and liver tumors are accepted as alternative procedure to open surgery. However, few studies reported outcomes of simultaneous laparoscopic surgery of these two procedures. The aim of this study was to compare short-term outcomes between laparoscopic and open approach. MATERIALS AND METHODS: Between June 2010 to December 2019, simultaneous laparoscopic cases were retrospectively matched (1:2) to open cases. Peri-operative and short-term outcomes were compared between both groups. RESULTS: Twelve patients in laparoscopic group were matched to 24 patients in open group according to age, gender, body mass index, american society of anesthesiologists physical status, preoperative laboratory data, number and size of liver metastases and extent of colorectal and liver resection, Most patients in each group had left-sided colon or rectal cancer and underwent wedge liver resection. The mean number of liver metastases was 1.3 vs 1.5 and size of liver metastases was 2.2 ± 1.4 vs 2.7 ± 1.1 cm in laparoscopic compared to open group. Estimated blood loss and length of hospital stay were significantly lower in laparoscopic group. However, operative time was significantly longer in laparoscopic group. Peri-operative complication was not significant difference between both groups and there was no mortality. CONCLUSION: Simultaneous laparoscopic colorectal surgery and minor liver resection is feasible and safe. Laparoscopic approach has better peri-operative outcome in term of shorter length of hospital stay compared to open approach.

Combination of Euro-Collins and University of Wisconsin Solution: An Effective and Economic Substitute for Organ Procurement.

PURPOSE: Many types of preservation fluid were used in liver procurement. Undoubtedly, the gold standard is the University of Wisconsin (UW) solution. But the solution is expensive. The aim of this study was to evaluate the results of combined acetated Ringer solution, Euro-Collins solution, and UW solution. MATERIALS AND METHODS: All patients undergoing adult liver transplantation from cadaveric donor during January 2013 to December 2017 in King Chulalongkorn Memorial Hospital were included in this study. Donor and recipient characteristics, preservation fluid, operative data, and postoperative outcomes were recorded. RESULTS: A total of 102 patients receiving liver transplants were enrolled into the study. The mean age of donors was 34.2 years. The mean total ischemic time was 420.93 minutes. In recipients, posttransplantation complications were the following: (1) primary nonfunction in 1 patient (0.98%); (2) early allograft dysfunction in 23 patients (22.5%); (3) hepatic artery thrombosis in 3 patients (2.7%); (4) hepatic venous outflow obstruction in 2 patients (1.96%); (5) biliary leakage in 1 patient (0.98%); (6) biliary anastomosis stenosis in 4 patients (3.92%); and (7) biliary nonanastomosis stenosis in 1 patient (0.98%). No inhospital mortality was occurred. Overall mortality rate is 7.8% (8/102). One-, 3-, and 5-year survival were 95.9%, 91.5%, and 88.4%, respectively. CONCLUSIONS: The combination of acetated Ringer solution, Euro-Collins solution, and UW solution is effective and economic for liver preservation. Further study should be conducted.

Improving the Surgical Outcomes after Liver Resection with ERAS Program.

Background: Enhanced recovery after surgery (ERAS) has been accepted as the program to improve the surgical outcomes. This program has been increasingly utilized in liver resection. Objective: To evaluate the outcomes of patients underwent liver resection by applying ERAS program. Material and Method: All patients underwent liver resection between January 2007 and April 2011 at King Chulalongkorn Memorial Hospital were included into the present study. Patients' characteristics, preoperative factors, operative data, postoperative care that correlated to ERAS components, and postoperative outcomes were recorded. Outcomes including postoperative length of stay (LOS), intensive care unit (ICU) stay, complications, rate of reoperation, interventional treatment, and mortality were compared between patients in ERAS group (applied ERAS components >4) and conventional group (applied ERAS components <4). Results: Three hundred forty seven patients were enrolled in present the study. There were 165 and 182 patients in ERAS and conventional groups, respectively. When compared between these two groups, ERAS group had better postoperative LOS (7 days vs. 10 days; p = 0.0001), ICU stay (0 days vs. 1 days; p = 0.0001), reoperation rate (1.2% vs. 4.9%; p = 0.047) and reintervention rate (15% vs. 27%; p = 0.005). There were no significant differences in complication rate (31% vs. 40%; p = 0.096) and mortality rate (0.6% vs. 1.1%; p = 0.62). Conclusion: ERAS program improves the surgical outcomes in patients who underwent liver resection.

Orthotopic liver transplantation at King Chulalongkorn Memorial Hospital: a report.

Orthotopic liver transplantation (LT) is the treatment of choice for various liver diseases including early hepatocellular carcinoma (HCC). After the first successful LT in Thailand at King Chulalongkorn Memorial Hospital (KCMH) in 1987, the number of LT has gradually been increasing in parallel with the improvement in patient survival. The recent outcomes of LT are reported herein. From January 1, 2002 to June 30, 2013, 120 cases of adult LT and 24 cases of pediatric LT were performed. The most common indication for LT was HCC in the adult whereas biliary atresia was the most common indication for LT in pediatric patients. As for the severity of liver disease, the average model of end stage liver disease (MELD) and pediatric end stage liver disease (PELD) scores were 19 in adult LT and 21.5 in pediatric LT respectively. The most common perioperative complication in adult LT was acute renal failure (25%). One-, five-year patient survival in adult LT and pediatric LT were 85%, 69% and 96%, 91%, respectively. In conclusion, the outcomes of LT at KCMH have gradually been improving close to the world standard, especially the patient survival.

Role of portal vein embolization in hepatobiliary malignancy.

BACKGROUND/AIMS: Inadequate remnant liver volume is the major cause of postoperative liver failure. Preoperative portal vein embolization (PVE) is the well accepted procedure to increase future liver remnant (FLR) volume and decrease the incidence of this complication. This study described the author's experience of preoperative PVE at King Chulalongkorn Memorial Hospital since 2002. METHODOLOGY: The clinical data of 29 patients who underwent PVE were reviewed. The FLR volumes before and after the procedure were calculated by CT volumetry. PVE was performed when estimated FLR volume was < 25% in normal liver or < 40% in damaged liver and also when major liver resection combined with major intraabdominal surgery was planned. The complications after PVE and hepatectomy were recorded. RESULTS: There were no deaths or complications after PVE. The mean growth of FLR was 11%. Power of liver regeneration was suboptimal in old age patients. Sixteen patients underwent liver resection (resectability rate 55.17%). There were 2 cases of postoperative hyperbilirubinemia (12.5%). The hospital mortality rate was 1/16 (6.25%). CONCLUSIONS: PVE is a useful and safe optional procedure to increase FLR. It not only reduces the postoperative liver failure but also increases the chance of curative resection.