Clinical implications of hepatitis B virus core antigen-mediated immunopathologic T cell responses in chronic hepatitis B.

Hepatitis B virus (HBV) infection significantly impacts Asian populations. The influences of continuous HBV antigen and inflammatory stimulation to T cells in chronic hepatitis B (CHB) remain unclear. In this study, we first conducted bioinformatics analysis to assess T-cell signaling pathways in CHB patients. In a Taiwanese cohort, we examined the phenotypic features of HBVcore -specific T cells and their correlation with clinical parameters. We used core protein overlapping peptides from the Taiwan prevalent genotype B HBV to investigate the antiviral response and the functional implication of HBV-specific T cells. In line with Taiwanese dominant HLA-alleles, we also evaluated ex vivo HBVcore -specific T cells by pMHC-tetramers targeting epitopes within HBV core protein. Compared to healthy subjects, we disclosed CD8 T cells from CHB patients had higher activation marker CD38 levels but showed an upregulation in the inhibitory receptor PD-1. Our parallel study showed HBV-specific CD8 T cells were more activated with greater PD-1 expression than CMV-specific subset and bulk CD8 T cells. Moreover, our longitudinal study demonstrated a correlation between the PD-1 fluctuation pattern of HBVcore -specific CD8 T cells and liver inflammation in CHB patients. Our research reveals the HBV core antigen-mediated immunopathologic profile of CD8 T cells in chronic HBV infection. Our findings suggest the PD-1 levels of HBVcore -specific CD8 T cells can be used as a valuable indicator of personal immune response for clinical application in hepatitis management.

Imaging differentiation of phytobezoar and small-bowel faeces: CT characteristics with quantitative analysis in patients with small- bowel obstruction.

OBJECTIVE: The objective is to use multidetector computed tomography (MDCT) to differentiate phytobezoar impaction and small-bowel faeces in patients with small-bowel obstruction (SBO). METHODS: We retrospectively reviewed 91 consecutive SBO patients with surgically proven phytobezoars (n = 31) or adhesion with small-bowel faeces (n = 60). Two readers blinded to the diagnosis recorded the following MDCT features: degree of obstruction, transition point, mesenteric fatty stranding, intraperitoneal fluid, air-fluid level, pneumatosis intestinalis, and portal venous gas. MDCT measurements of the food debris length, attenuation, luminal diameter, and wall thickness of the obstructed bowel were also compared. RESULTS: A higher grade of obstruction with an absence of mesenteric fatty stranding and intraperitoneal fluid was more commonly seen in the phytobezoar group than in the small-bowel faeces group (p < 0.01). The food debris length (phytobezoar, 5.7 ± 2.8 cm; small-bowel feces, 20.3 ± 7.9 cm, p < 0.01) and mean attenuation (phytobezoar, -59.6 ± 43.3 Hounsfield units (HU); small-bowel faeces, 8.5 ± 7.7 HU, p <0.01) were significantly different between the two groups. The ROC curve showed that food debris length <9.5 cm and mean attenuation value < -11.75 HU predicted phytobezoar impaction. CONCLUSIONS: MDCT features with measurements of the food debris length and mean attenuation assist the differentiation of phytobezoar impaction and small-bowel faeces. KEY POINTS: • MDCT examination helps to differentiate phytobezoar and small-bowel faeces. • A higher grade of obstruction is commonly associated with phytobezoar impaction. • Mesenteric fatty stranding and intraperitoneal fluid are frequently associated with small-bowel faeces. • Quantitative measurement of the obstructed bowel adds the diagnostic accuracy.

Beneficial Effect of Combining Radiotherapy and Transarterial Chemoembolization on Patient Survival in Hepatocellular Carcinomas and Macrovascular Invasion Treated with Sorafenib.

BACKGROUND: Approximately 10-40% of hepatocellular carcinoma (HCC) patients have definite vascular invasion at the time of diagnosis. Without curative treatment options, these patients have an abysmal prognosis with a median survival of only a few months following systemic therapy. However, supportive evidence of combining multiple locoregional treatments with systemic therapy is limited. This study compared the outcomes of sorafenib alone versus multimodality therapy with sorafenib, radiotherapy (RT), and transarterial chemoembolization (TACE) in advanced HCC patients with macrovascular invasion (MaVI). METHODS: The process took place over a nine-year period between March 2009 and October 2017, wherein 78 HCC patients with MaVI who underwent either sorafenib therapy alone (n = 49) or combined sorafenib/RT/TACE (n = 29) therapy were chosen for the retrospective study. We compared the overall survival (OS) between the two groups using the Cox regression hazard model and adjusted imbalances using propensity score matching (PSM). RESULTS: At the last follow-up, 76 patients had died, with a median follow-up time of 4.8 months for all patients and 31 months for those who were alive. Patients treated with sorafenib/RT/TACE had superior OS compared to those treated with sorafenib alone, showing a median survival of 9.3 vs. 2.7 months and a one-year survival of 37.1% vs. 6.1% (p < 0.001). In the multivariable analysis, new diagnosis or recurrence of HCC and treatment modalities (sorafenib alone vs. sorafenib/RT/TACE) were independent prognostic factors for OS. Compared to patients treated with sorafenib alone, significantly better OS was further verified using PSM (p < 0.001) in patients who received multiple therapeutic modalities. CONCLUSION: Multimodality therapy with sorafenib/RT/TACE increased OS threefold versus sorafenib therapy alone in HCC patients with MaVI. This study offers promising benefits of combined locoregional and systemic therapy for advanced HCC in current patient management and prospective clinical trials.

Management of spontaneously ruptured hepatocellular carcinoma and hemoperitoneum manifested as acute abdomen in the emergency room.

BACKGROUND: Spontaneously ruptured hepatocellular carcinoma (HCC) with hemoperitoneum has a poor prognosis, especially in cases of cirrhosis. Patients usually present to emergency rooms (ERs) with acute abdomen. The aim of the present study was to determine the factors affecting mortality and to compare the prognosis of conservative treatment, transcatheter arterial embolization (TAE), or hepatectomy in these situations. METHODS: Fifty-four patients with spontaneously ruptured HCC diagnosed between January 2004 and August 2010 were enrolled in this retrospective review of clinical data. Grouping by survival or mortality, univariate and multivariate analyses of factors affecting 30-day mortality, and long-term survival were conducted. The outcomes of the various treatments were analyzed. RESULTS: After primary fluid resuscitation in the ER, 6 of 54 patients underwent conservative treatment. Emergency hepatectomy was performed on 19 patients; TAE was used for 29 patients, 18 of whom received staged hepatectomy thereafter. Poor liver function, prolonged international normalized ratio (INR), and conservative treatment were associated with increased 30-day mortality. Logistic regression analysis of cumulative survival revealed that INR ≥ 1.4, multiple intrahepatic HCC, and conservative treatment were related to poorer long-term survival. The patients who received hepatectomy, either immediate or staged after TAE, had higher survival rates of 85.2 % at 30 days and 62.2 % at 1 year. CONCLUSIONS: The treatment of ruptured HCC should be tailored to the individual case. Prolonged survival is possible in patients with preserved liver function through curative liver resection. Emergency physicians, radiologists, and surgeons play essential roles in managing these patients.

Liver transplantation with simultaneous splenectomy increases risk of cancer development and mortality in hepatocellular carcinoma patients.

BACKGROUND: Splenectomy has previously been found to increase the risk of cancer development, including lung, non-melanoma skin cancer, leukemia, lymphoma, Hodgkin's lymphoma, and ovarian cancer. The risk of cancer development in liver transplantation (LT) with simultaneous splenectomy remains unclear. AIM: To compare hepatocellular carcinoma (HCC) recurrence and de novo malignancy between patients undergoing LT with and without simultaneous splenectomy. METHODS: We retrospectively analyzed the outcomes of 120 patients with HCC within the University of California San Francisco criteria who received LT with (n = 35) and without (n = 85) simultaneous splenectomy in the Tri-Service General Hospital. Univariate and multivariate Cox regression analyses for cancer-free survival and mortality were established. The comparison of the group survival status and group cancer-free status was done by generating Kaplan-Meier survival curves and log-rank tests. RESULTS: The splenectomy group had more hepatitis C virus infection, lower platelet count, higher -fetoprotein level, and longer operating time. Splenectomy and age were both positive independent factors for prediction of cancer development [hazard ratio (HR): 2.560 and 1.057, respectively, P < 0.05]. Splenectomy and hypertension were positive independent factors for prediction of mortality. (HR: 2.791 and 2.813 respectively, P < 0.05). The splenectomy group had a significantly worse cancer-free survival (CFS) and overall survival (OS) curve compared to the non-splenectomy group (5-year CFS rates: 53.4% vs 76.5%, P = 0.003; 5-year OS rate: 68.1 vs 89.3, P = 0.002). CONCLUSION: Our study suggests that simultaneous splenectomy should be avoided as much as possible in HCC patients who have undergone LT.

In Vitro Cell Density Determines the Sensitivity of Hepatocarcinoma Cells to Ascorbate.

Hepatocellular carcinoma (HCC) is the primary histological subtype of liver cancer, and its incidence rates increase with age. Recently, systemic therapies, such as immune checkpoint inhibitors, monoclonal antibodies, and tyrosine kinase inhibitors (TKIs), have been more beneficial than conventional therapies for treating HCC. Nonetheless, the prognosis of late-stage HCC remains dismal because of its high recurrence rates, even with substantial advances in current therapeutic strategies. A new treatment, such as a combination of current systemic therapies, is urgently required. Therefore, we adopted a repurposing strategy and tried to combine ascorbate with TKIs, including lenvatinib and regorafenib, in HepG2 and Hep3B cells. We investigated the potential functional impact of pharmacological concentrations of ascorbate on the cell-cycle profiles, mitochondrial membrane potential, oxidative response, synergistic effects of lenvatinib or regorafenib, and differential responsiveness between HepG2 and Hep3B cells. Our data suggest that the relative level of cell density is an important determinant for ascorbate cytotoxicity in HCC. Furthermore, the data also revealed that the cytotoxic effect of pharmacological concentrations of ascorbate might not be mediated via our proposed elevation of ROS generation. Ascorbate might be involved in redox homeostasis to enhance the efficacy of TKIs in HepG2 and Hep3B cells. The synergistic effects of ascorbate with TKIs (lenvatinib and regorafenib) support their potential as an adjuvant for HCC targeted TKI therapy. This research provides a cheap and new combinatory therapy for HCC treatment.

Prophylactic hyperthermic intraperitoneal chemotherapy for patients with clinical T4 gastric cancer.

INTRODUCTION: Patients with clinical T4 gastric cancers have high recurrence rates and low 5-year overall survival (OS) despite radical gastrectomy with D2 lymphadenectomy and adjuvant chemotherapy. The invisible peritoneal metastasis may result in local recurrence due to the tumor invading the serosa and nearby organs. Prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) has been suggested as an adjuvant treatment strategy in these patients. We evaluated the efficacy of prophylactic HIPEC post-gastrectomy for patients with clinical T4 gastric cancer. MATERIALS AND METHODS: We retrospectively reviewed data from 132 patients with clinical T4 gastric cancer who underwent gastrectomy + D2 lymphadenectomy between 2014 and 2020. Thirty-five of these patients also underwent prophylactic HIPEC perioperatively. We used propensity score matching (PSM) to reduce selection bias. We evaluated the risk factors for recurrence and compared the OS and disease-free survival (DFS) between the gastrectomy and prophylactic HIPEC groups. RESULTS: A total of 132 eligible patients were included in the study. Seventy preoperative patient characteristics were homogeneous post-PSM. Prophylactic HIPEC seemed to reduce the risk of postoperative peritoneal recurrence but did not influence the risk of distant metastasis. The risk factors for recurrence included advanced N stage, ascites, and lymphovascular invasion. OS (adjusted hazard ratio, 0.37; 95% CI, 0.17 to 0.81; p = 0.035) and DFS (adjusted hazard ratio, 0.33; 95% CI, 0.15 to 0.72; p = 0.017) were better in the prophylactic HIPEC group than in the gastrectomy alone group. CONCLUSIONS: Prophylactic HIPEC plus radical gastrectomy can reduce peritoneal recurrence and improve OS and DFS in patients with clinical T4 gastric cancer.

Conversion Surgery for Patients with Advanced Gastric Cancer with Peritoneal Carcinomatosis.

BACKGROUND: Patients with advanced gastric cancer (AGC) with peritoneal carcinomatosis (PC) usually have poor outcomes and high mortality risk, even with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). This study analyzed the prognostic factors of AGC with PC and evaluated laparoscopic HIPEC (LHIPEC) plus neoadjuvant intraperitoneal and systemic chemotherapy (NIPS) as a conversion surgery for AGC patients with PC with a poor initial prognosis. Patient and Methods. We retrospectively evaluated 127 patients with AGC and PC from January 1, 2012, to March 1, 2020. After the exclusion of 32 ineligible patients, the conversion group comprised 34 patients who underwent LHIPEC + NIPS as a conversion surgery followed by CRS plus HIPEC. The CRS + HIPEC group included 15 patients who underwent CRS with HIPEC alone. Additionally, the C/T group comprised 23 patients who received systemic chemotherapy, and the palliative group comprised 23 patients who received only conservative therapy or palliative gastrectomy. RESULTS: The conversion group demonstrated a significantly better mean overall survival compared to the CRS + HIPEC, C/T, and palliative groups (p < 0.001). Patients in the conversion group who underwent LHIPEC + NIPS had significantly decreased peritoneal cancer index (PCI) scores (p < 0.001) and ascites (p=0.003). Malignant ascites amount also significantly decreased after treatment in the LHIPEC + NIPS group (p < 0.001). CONCLUSIONS: LHIPEC + NIPS can significantly improve the overall survival, the PCI score, and malignant ascites amount in peritoneal cytology-positive gastric cancer with PC, and an initially high PCI score. Therefore, it may be a feasible conversion strategy for AGC patients with PC.

Outcomes of Infection and Risk of Mortality in Liver Transplant Patients with Simultaneous Splenectomy.

PURPOSE: The purpose of this study was to compare the outcomes of infection between liver transplant patients with and without simultaneous splenectomy. METHODS: We retrospectively analyzed the records of 211 patients who underwent liver transplantation in the Tri-Service General Hospital from 2012 to 2017. The frequency of blood cultures obtained after liver transplantation; incidence of bacteremia, pathogens, and complications; and overall survival rates were compared between the groups. RESULTS: One hundred thirty-three of 211 patients underwent liver transplantation without simultaneous splenectomy. There were no significant differences in the frequency of blood cultures obtained after liver transplantation (non-splenectomy group and splenectomy group: 63% and 62%, respectively); incidences of bacteremia after liver transplantation (21% and 21%, respectively), repeat bacteremia (39% and 35%, respectively), cytomegalovirus infection (4% and 3%, respectively), herpes infection (6% and 7%, respectively), and fungal infection (3% and 3%, respectively); and overall survival rate between the two groups. However, there was a significant difference in infection-related deaths between the groups. Simultaneous splenectomy and episodes of antibody-related rejection were significant risk factors associated with infection-related death in multivariate analyses. CONCLUSION: Although simultaneous splenectomy does not increase the incidence of infection, simultaneous splenectomy definitely carries risks of infection-related mortality in liver transplantation.

Comparing hepatic resection and transarterial chemoembolization for Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma: change for treatment of choice?

BACKGROUND: Compared to transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC), stage B in the Barcelona Clinic Liver Cancer (BCLC) classification, the role of hepatic resection remains unclear. The present study compared the long-term outcome of hepatic resection with TACE in the treatment of BCLC stage B HCC. METHODS: A total of 171 patients with BCLC stage B, Child's classification A (Child A), HCC were included in this retrospective study. Of these, 93 patients underwent hepatic resection (group I) and 73 patients received TACE (group II). We evaluated the long-term outcome and therapy-related mortality in both groups. The risk factors of mortality were assessed. The survival curve was analyzed by the Kaplan-Meier method. RESULTS: The 1-, 2-, and 3-year overall survival rates for the two groups after hepatic resection and TACE were 83%, 62%, 49% and 39%, 5%, 2%, respectively (P < 0.0001). We did not observe significant differences in the therapy-related mortality between the two groups (P = 0.78). Treatment modality and serum albumin level were independent risk factors for survival by Cox regression analysis. CONCLUSIONS: Our study demonstrated that hepatic resection for BCLC stage B, Child A HCC patients had better survival rates than TACE group. Thus, hepatic resection is indicated in selected patients with BCLC stage B.

Overdose of Tacrolimus as the Trigger Causing Progression of Posterior Reversible Encephalopathy Syndrome and Subsequent Hepatic Infarction After Liver Transplant: A Case Report.

Posterior reversible encephalopathy syndrome is a neurotoxic state accompanied by unique brain imaging patterns and neurologic abnormalities, typically associated with several complex clinical conditions such as preeclampsia/eclampsia, solid-organ transplant procedures, autoimmune diseases, and immunosuppressive agents. The detailed mechanism of posterior reversible encephalopathy syndrome is not known, and the current therapy is only supportive care. Here, we present a 33-year-old parturient woman with preeclampsia complicated with hemolysis, elevated liver enzymes, and low platelet syndrome, fulminant hepatitis B, acute fatty liver, and posterior reversible encephalopathy syndrome. The patient developed gross hepatic infarction soon after liver transplant. After several possible causes were excluded, we found that progression of underlying posterior reversible encephalopathy syndrome-induced endothelial damage by overdose of tacrolimus may have been the major cause for deteriorating hypoperfusion of the transplanted liver and fatal graft failure. In liver transplant recipients, severe posttransplant hypoperfusion of the grafted liver may result in loss of the liver allograft and even mortality. Poor control of underlying posterior reversible encephalopathy syndrome-associated endothelial damage because of tacrolimus overdose may lead to severe hypoperfusion of grafted hepatic vessels and subsequent hepatic infarction. This report highlights tacrolimus as a potential trigger of posterior reversible encephalopathy syndrome and may inform clinical decisions regarding tacrolimus administration in liver transplant recipients with preexisting or newly developed posterior reversible encephalopathy syndrome.

Somatostatin Therapy in Patients with Massive Ascites After Liver Transplantation.

BACKGROUND Patients with massive ascites (MA) after liver transplantation (LT, defined here as daily ascitic drainage more than 1000 ml per day for more than 7 days after liver transplantation) are at increased risks of infection, hypoalbuminemia, graft loss, and even mortality. The aim of this retrospective cohort study was to investigate the effects of somatostatin on patients with MA after LT. MATERIAL AND METHODS Twenty-eight patients with liver cirrhosis or hepatocellular carcinoma who underwent LT complicated by MA postoperatively were included. Ten participants were receiving somatostatin therapy. The postoperative course and adverse drug effects were investigated. Daily postoperative ascitic drainage and urine output were also recorded and compared to those in the non-somatostatin group. RESULTS The somatostatin group had significantly less ascites drainage after LT compared to the non-somatostatin group (p=0.002). Urine output was significantly increased after somatostatin administration (p<0.001). No serious adverse effects influencing graft function or fatal complications occurred after somatostatin therapy. CONCLUSIONS Somatostatin treatment is beneficial for the management of MA after liver transplantation.

Twice-Weekly Tacrolimus Can Overcome Pharmacologic Interaction and Help in the Successful Treatment of Pulmonary Aspergillosis in a Liver Transplant Recipient.

Drug-drug interactions between azoles and calcineurin inhibitors can cause issues for organ transplant specialists. Clinical practice guidelines for the treatment of solid-organ transplant recipients with invasive aspergillosis infection are lacking. Here, we present a patient who developed pulmonary aspergillosis after liver transplant. The patient had prolonged treatment with echinocandin that was not effective. A drug-drug interaction between azoles and tacrolimus caused issues for the clinical physician. We adjusted the doses, and the patient was successfully treated. A reduction in the tacrolimus dose, intensive monitoring of associated parameters, and elimination of risk exposures are important for a favorable outcome.

Ovarian metastases from gallbladder mimics primary ovarian neoplasm in young patient: a case report.

BACKGROUND: Gallbladder cancer is unusually seen but can result in highly mortality rate. It makes challenge to diagnose for clinicians due to present asymptomatic or non-specific clinical presentation including abdominal pain, anorexia. It usually also accompanies with cholelithiasis (incidence is 1-2%) and incidentally detected by radiologic examination such as ultrasound, computed tomography or intra-operative intervention accidentally. Gallbladder cancer results in highly fatal malignancy because it is difficult to early detect. The ovarian metastases from gallbladder mimics primary neoplasm isn't seen before and mentioned in English literatures before. CASE PRESENTATION: A 28-year-old woman suffered from intermittently lower abdominal tenderness and nausea after meals for 3 years. The abdominal ultrasound revealed a right ovarian mass with fluid accumulation and the contrast CT of abdomen revealed a gallbladder fundus mass and liver tumor lesion located at segment 4. We arranged surgical intervention with radical cholecystectomy and debulking operation with salpingo-oophorectomy. The pathologic report revealed adenocarcinoma of gallbladder with liver, peritoneum, and right ovarian invasion. After surgical intervention, she also received adjuvant chemotherapy with Gemcitabine, Cetuximab, Cisplatin and Cyberknife. CONCLUSION: The non-specific symptoms make the challenge to difference the primary malignant neoplasm. The rarely diagnosis must take in consider if the gastrointestinal tract tumours coexist with ovarian tumours.

Acute appendicitis complicated with necrotizing fasciitis in a patient with adult-onset Still's disease: A case report.

RATIONALE: Adult-onset Still disease (AOSD) is a rare systemic inflammatory disease of unknown etiology characterized by evanescent salmon-pink rash, spiking fever, arthralgia/ arthritis, and lymphadenopathy. AOSD sometimes was fatal when it is complicated by macrophage activation syndrome (MAS) or hemophagocytic lymphohistiocytosis (HLH). Nonetheless, the literature provides no recommendations for treatment of AOSD patients with severe sepsis. PATIENT CONCERNS: A previously healthy 65-year-old man with history of AOSD was referred to our hospital for persistent right lower quadrant abdominal pain for 2 days. One week later, an abdominal wall abscess and hematoma developed by extravasation from the inferior epigastric vessels, complicated by necrotizing fasciitis of the right thigh and groin region. To our best knowledge, this case was the first reported case of a perforated appendix complicated with necrotizing fasciitis in a patient with AOSD. DIAGNOSES: The patient was diagnosed as acute appendicitis complicated with necrotizing fasciitis and abdominal wall abscess. INTERVENTIONS: This case received intravenous tigecycline injection and daily 10 mg prednisolone initially, and shifted to daily intravenous hydrocortisone 200 mg for suspected MAS or HLH. This patient underwent surgical intervention and debridement for necrotizing fasciitis. OUTCOMES: The patient's symptoms progressed worse rapidly. He died from cytomegalovirus viremia and bacterial necrotizing fasciitis complicated by septic shock. LESSONS: (1) The steroid dose was difficult to titrate when AOSD complicated by sepsis. The differential diagnosis from MAS/HLH with bacterial/viral infection related severe sepsis was difficult but critical for decision making from clinicians and rheumatologists. (2) The conservative treatment with antibiotics for perforated appendix is safe but has a higher failure rate in immunocomprised patients such as systemic lupus erythematosus and AOSD. Early surgical intervention might contribute to better outcome. (3) The abdominal wall abscess can be spread from intra-abdominal lesion through the inferior epigastric vessels which were as weak points of abdominal wall. Imaging examinations contribute to acute diagnosis and help surgeons perform surgical interventions to prevent morbidity and mortality.

Long-term outcomes in elderly patients with resectable large hepatocellular carcinoma undergoing hepatectomy.

BACKGROUND: In contrast to the feasibility of hepatectomy for resectable large hepatocellular carcinoma (HCC, >5 cm) in the younger patients, the concerns of benefits for the elderly patients remain in practice. This study aimed to evaluate the long-term outcomes and safety after hepatectomy in elderly patients with resectable large HCC compared with younger patients. METHODS: Between 2003 and 2014, a total of 2211 HCC patients were reviewed using a prospective database and 257 patients with resectable large HCC undergoing hepatectomy were included: 79 elderly patients with age ≥70 years and 178 younger patients with age <70 years. The last follow-up was assessed in December 2017. The complications, long-term outcomes and risk factors of disease-free and overall survival were analysed. RESULTS: The 1-, 3-, 5- and 7-year overall survival rates in the elderly and younger groups were 76%, 55%, 48%, and 42% and 79%, 57%, 51%, and 49%, respectively (P = 0.319). The 1-, 3-, 5-, and 7-year disease-free survival rates in the elderly and younger groups were 60%, 40%, 38%, and 27% and 54%, 36%, 32%, and 32%, respectively (P = 0.633). The analysis of post-operative outcomes of interest, including hospital stay and hospital death and hepatectomy-related complications in both groups revealed no significant difference. Serum albumin and AJCC TNM stage were independent risk factors for survival. Serum alpha-fetoprotein, tumour number and AJCC TNM stage predicted HCC recurrence. CONCLUSIONS: Our results suggested that hepatectomy can achieve comparable long-term outcomes in the selected younger and elderly patients with resectable large HCC.

Comprehensive risk assessment for early neurologic complications after liver transplantation.

AIM: To determine risk factors for early neurologic complications (NCs) after liver transplantation from perspective of recipient, donor, and surgeon. METHODS: In all, 295 adult recipients were enrolled consecutively between August 2001 and February 2014 from a single medical center in Taiwan. Any NC in the first 30 d post-liver transplantation, and perioperative variables from multiple perspectives were collected and analyzed. The main outcome was a 30-d NC. Generalized additive models were used to detect the non-linear effect of continuous variables on outcome, and to determine cut-off values for categorizing risk. Risk factors were identified using multiple logistic regression analysis. RESULTS: In all, 288 recipients were included, of whom 142 (49.3%) experienced at least one NC, with encephalopathy being the most common 106 (73%). NCs prolonged hospital stay (35.15 ± 43.80 d vs 20.88 ± 13.58 d, P < 0.001). Liver recipients' age < 29 or ≥ 60 years, body mass index < 21.6 or > 27.6 kg/m(2), Child-Pugh class C, history of preoperative hepatoencephalopathy or mental disorders, day 7 tacrolimus level > 8.9 ng/mL, and postoperative intra-abdominal infection were more likely associated with NCs. Novel risk factors for NCs were donor age < 22 or ≥ 40 years, male-to-male gender matching, graft-recipient weight ratio 0.9%-1.9%, and sequence of transplantation between 31 and 174. CONCLUSION: NCs post- liver transplantation occurs because of factors related to recipient, donor, and surgeon. Our results provide a basis of risk stratification for surgeon to minimize neurotoxic factors during transplantation.

Comparison of Ischemic and Nonischemic Bowel Segments in Patients With Mesenteric Ischemia: Multidetector Row Computed Tomography Findings and Measurement of Bowel Wall Attenuation Changes.

OBJECTIVE: To describe multidetector row computed tomography (MDCT) findings and to compare the enhancing ratio of ischemic and nonischemic bowel wall segments in patients with mesenteric ischemia. PATIENTS AND METHODS: We performed a retrospective review of 69 patients with pathologically proven mesenteric ischemia who underwent a preoperative MDCT evaluation from January 1, 2010, through December 31, 2014. Two reviewers performed quantitative MDCT measurements of the bowel wall attenuation of the ischemic and nonischemic bowel segments on the unenhanced phase, arterial phase, and portal venous phase. Receiver operating characteristic curves for the enhancing ratios on the arterial phase and portal venous phase (ERv) were calculated to discriminate the 2 segments. A concordance correlation coefficient was used to assess interobserver variability. RESULTS: The most common origin of ischemia was the mesenteric artery (45 of the 69 patients [65.2%]), but only 5 patients (7.2%) had evidence of arterial thrombus on MDCT. The quantitative MDCT measurements indicated that the ischemic bowel segments had significantly less bowel wall attenuation than the nonischemic bowel segments on the arterial phase (28.58±9.28 vs 58.97±12.50; P<.001) and the portal venous phase (33.93±11.16 vs 76.25±13.56; P<.001). The enhancing ratio on the arterial phase (cutoff, 0.32 or less; sensitivity, 89.9%; specificity, 98.6%) and the ERv (cutoff, 0.81 or less; sensitivity, 95.7%; specificity, 98.6%) predicted bowel ischemia. The most common MDCT findings in ischemic bowel were thickened bowel wall in 59 patients (85.5%), mesenteric fatty stranding in 57 (82.6%), and decreased bowel wall enhancement in 56 (81.2%). All quantitative measurements reached moderate to substantial agreement (0.399-0.601). CONCLUSION: Without oral contrast administration and at a constant 120-peak kilovolt setting, MDCT findings of decreased enhancement of the thickened bowel wall together with a low ERv value predicted the presence of an ischemic bowel segment.