When to call it off: defining transplant candidacy limits in liver donor liver transplantation for hepatocellular carcinoma.

BACKGROUND: Living donor liver transplantation (LDLT) is an acceptable treatment option for hepatocellular carcinoma (HCC). Traditional transplant criteria aim at best utilization of donor organs with low risk of post transplant recurrence. In LDLT, long term recurrence free survival (RFS) of 50% is considered acceptable. The objective of the current study was to determine preoperative factors associated with high recurrence rates in LDLT. METHODS: Between April 2012 and December 2019, 898 LDLTs were performed at our center. Out of these, 242 were confirmed to have HCC on explant histopathology. We looked at preoperative factors associated with ≤ 50%RFS at 4 years. For survival analysis, Kaplan Meier curves were used and Cox regression analysis was used to identify independent predictors of recurrence. RESULTS: Median AFP was 14.4(0.7-11,326.7) ng/ml. Median tumor size was 2.8(range = 0.1-11) cm and tumor number was 2(range = 1-15). On multivariate analysis, AFP > 600 ng/ml [HR:6, CI: 1.9-18.4, P = 0.002] and microvascular invasion (MVI) [HR:5.8, CI: 2.5-13.4, P <  0.001] were independent predictors of 4 year RFS ≤ 50%. When AFP was > 600 ng/ml, MVI was seen in 88.9% tumors with poor grade and 75% of tumors outside University of California San Francisco criteria. Estimated 4 year RFS was 78% for the entire cohort. When AFP was < 600 ng/ml, 4 year RFS for well-moderate and poor grade tumors was 88 and 73%. With AFP > 600 ng/ml, RFS was 53% and 0 with well-moderate and poor grade tumors respectively (P <  0.001). CONCLUSION: Patients with AFP < 600 ng/ml have acceptable outcomes after LDLT. In patients with AFP > 600 ng/ml, a preoperative biopsy to rule out poor differentiation should be considered for patient selection.

Patient Selection for Living Donor Liver Transplantation in Acute-on-chronic Liver Failure.

Background and objectives: Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality without liver transplantation (LT). The selection criteria for LT in these patients are not well defined. The objective of this study was to determine factors associated with post-transplant survival in ACLF. Methods: This was a single-center retrospective study of patients who underwent living donor liver transplantation (LDLT) for ACLF between 2012 and 2022. Out of 1093 transplants, 110 patients had underlying ACLF, based on the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. We looked at factors associated with 1-year posttransplant survival. Results: The median model for end-stage liver disease (MELD) score was 33.5 (31-38), and the 1-year posttransplant survival was 72%. Six risk factors were associated with posttransplant survival, namely, body mass index > 30 kg/m2 [HR, 4.4; 95% CI, 1.8-10.7], platelet count < 66,000/µl [HR, 2.91; CI,1.2-6.6], poor response to medical treatment [HR, 2.6; CI, 1.1-5.7], drug-resistant bacterial or fungal cultures [HR, 4.2; CI, 1.4-12.4], serum creatinine > 2.5 mg/dl [HR, 3.4; CI, 1.5-7.7], and graft-to-recipient weight ratio < 0.7 [HR, 4.8; CI, 1.4-16.3]. The 1-year post-transplant survival was 84% in patients with 0-2 risk factors (n = 89) and was 6% with 3 risk factors (n = 15) (P < 0.001). For 1-year posttransplant survival, the area under curve (AUC) for the current model was 0.8 (0.69-0.9). The AUC for CLIF-ACLF, Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), and EASL-CLIF ACLF grades was < 0.5. Conclusion: In LT for ACLF, acceptable survival can be achieved when less than three high-risk factors are present.

Improving the quality of care for medical inpatients by placing a higher priority on ward rounds.

Models suggested for managing acute, non-elective, medical admissions include expanding geriatric services, extending the role of the acute physician and rejuvenating the role of the general physician. We investigated improving inpatient care by changing consultants' work patterns and placing a higher priority on the ward rounds. A focus group and a questionnaire were used to study the impact on several ward round parameters. All respondents reported an overall satisfaction: 93% rated the quality of care as good or excellent, 75% reported increased safe patient discharges and 68% observed improved teamwork. Length of stay reduced to 4 days from 5.3 days without an increase in readmission. The main themes showed improved quality of care, better assured patients and relatives, and better consultant job satisfaction, but also showed reduced junior doctors' independent decision-making and a slight reduction in specialty-related activity. The study concluded that placing a higher priority on ward rounds by altering consultants' work patterns has a positive impact on inpatient care.

Effects of smoking on length of hospital stay in patients surviving an orthotopic liver transplant.

BACKGROUND: Smoking in orthotopic liver transplant (OLT) recipients has been associated with increased risk of vascular complications, cardiac events, graft failure and oesophegeal cancer. The aim of this study was to determine the effect of smoking on length of hospital stay post OLT and also to audit support provided to these patients. METHODS: This was a retrospective study carried out in the Liver Transplant Unit, St James University Hospital, UK from 1979 to 2005. One hundred seventy-four 174 adult patients who had undergone OLT in this hospital during this time with a follow-up of at least 2 years after transplantation were included. RESULTS: One hundred seventy-four 174 patients (mean age 52.2 years) responded by answering the questionnaire. Answers were analysed using relevant statistical methods. Eighty 80 patients had a smoking history (ever-smoked) while 94 were non-smokers (never-smoked). Out of 56 patients with a smoking history, 46% (n = 26) were offered advice and only 18% (n = 10) were offered any support. Of the 26 patients smoking at the time of OLT, 58% (n = 15) were offered advice and only 19% (n = 5) had been offered support. There was no significant difference in length of hospital stay post OLT between patients who had never-smoked and ever-smoked (p = 0.780). In addition, smoking at the time of OLT had no significant impact on length of hospital stay (p = 0.922). CONCLUSIONS: Smoking per se does not seem to increase hospital stay post OLT. Patients should be adequately counselled about smoking post OLT. Support mechanisms, including better awareness among doctors and allied healthcare workers should be made available to tackle this problem.

Survival after extended resections for gallbladder cancer.

Backgrounds/Aims: Locally advanced gallbladder cancer (GBC) is associated with survival limited to a few months. Extended resections (ER) are occasionally performed in this group and outcomes remain inconclusive. This study assessed outcomes after ER for locally advanced GBC. Methods: Patients who underwent ER for GBC between 2011 and 2020 were reviewed. ER was defined as a major hepatectomy alone (n = 9), a pancreaticoduodenectomy (PD) with or without minor hepatectomy (n = 3), a major hepatectomy with PD (HPD) (n = 3) or vascular resection and reconstruction (n = 4). We assessed 30-day morbidity, mortality, and 2-year overall survival (OS). Results: Among 19 patients, negative margins were achieved in 14 (73.6%). The 30-day mortality was 1/9 (11.1%) for a major hepatectomy, 0/3 (0%) for a minor HPD, 2/3 (66.7%) for a major HPD, and 1/4 (25.0%) for vascular resection. All short term survivors (< 6 months) (n=8) had preoperative jaundice and 6/8 (75.0%) underwent a major HPD or vascular resection. There were five (26.3%) long term survivors. The median OS in patients with and without preoperative jaundice was 4.1 months (0.7-11.1 months) and 13.7 months (12-30.4 months), respectively (p = 0.009) (2-year OS = 7% vs. 75%; p = 0.008). The median OS in patients who underwent a major hepatectomy alone or a minor HPD was 11.3 months (6.8-17.3 months) versus 1.4 months (0.3-4.1 months) (p = 0.02) in patients who underwent major HPD or vascular resection (2 year OS = 33% vs. not reached) (p = 0.010) respectively. Conclusions: In selected patients with GBC, when ER is limited to a major hepatectomy alone, or a minor HPD, acceptable survival can be achieved.

Multivisceral central pancreatectomy for pancreatic neuroendocrine tumor: A case report on a novel surgical technique.

INTRODUCTION: Central pancreatectomy (CP) is considered a viable alternative to subtotal distal pancreatectomy, for lesions involving the neck or proximal pancreatic body. Multivisceral central pancreatectomy (MVCP) for locally advanced tumors of the pancreatic body remains unreported. PRESENTATION OF CASE: We hereby report a case of locally advanced pancreatic neuroendocrine tumor (NET) with gastric involvement. The patient underwent successful central pancreatectomy with subtotal gastrectomy for locally advanced NET of the pancreas. In the follow up period, relevant complications like pancreatic insufficiency or pancreatic fistula were not encountered. The patient is doing well more than ten months after resection. DISCUSSION: A MVCP can be considered in patients with limited pancreatic involvement, as long as sufficient pancreatic parenchyma can be preserved. Additional organ involvement mandating resection should not be considered a contra indication to this procedure. With careful surgical planning and meticulous technique, risk of post operative complications after MVCP can be minimized with added benefit of long term endocrine and exocrine integrity. CONCLUSIONS: CP is a viable alternative and can be performed with adjacent organ resection, with acceptable post operative outcomes.

Pancreatic Tuberculosis: A Diagnostic Dilemma.

Despite the high prevalence of tuberculosis (TB) in developing countries, pancreatic TB remains a rare disease. Pancreatic TB usually presents as fever, night sweats, and abdominal pain in an immunocompromised individual. We present a case of a patient with end-stage renal disease undergoing pre-transplant workup who had an incidental finding of a pancreatic mass and necrotic peri-pancreatic lymph nodes on a CT scan. The patient was diagnosed via endoscopic ultrasound-guided biopsy as pancreatic TB. Anti-TB therapy was started with positive results.

Khat (Catha Edulis) as a possible cause of autoimmune hepatitis.

AIM: To investigate the potential role of khat in triggering auto immune hepatitis. METHODS: Patients with a history of khat use and acute hepatitis were identified using the computer database in the hepatology department at the Royal Hallamshire Hospital. They were then assessed for probability of having autoimmune hepatitis using the revised autoimmune hepatitis scoring criteria. RESULTS: Six patients were identified. All of them had presented with acute hepatitis on a background of khat. All were male and five of these patients were of Somali origin, while one patient was from Yemen. The patients were given points on the modified autoimmune hepatitis score which is based on their liver enzymes, autoimmune screen, exclusion of viral hepatitis alcohol and drugs, immunoglobulin levels and liver histology. The patients were given a score of -4 for khat use due to its potential to cause drug induced liver injury. Five of these patients scored between 10 and 15 points, placing them in the probable group for having autoimmune hepatitis. All of these patients were treated with prednisolone and demonstrated a good response to immunosuppression. CONCLUSION: One possibile cause of hepatotoxicity with khat could be via triggering of autoimmune hepatitis in a genetically susceptible individual. Further studies are needed for confirmation.