Plasma B-cell activating factor levels and polymorphisms in hepatitis B-related hepatocellular carcinoma: Clinical correlation and prognosis.

BACKGROUND: B-cell activating factor (BAFF), an important cytokine for B lymphocyte activation, has been shown to be increased in chronic hepatitis B virus (HBV) infection. OBJECTIVE: This study aimed at evaluating clinical correlation and prognostic role of plasma BAFF and related polymorphisms in patients with HBV-related hepatocellular carcinoma (HCC). METHODS: Plasma BAFF levels were measured from 100 healthy controls and 490 patients with chronic HBV infection (200 with HCC and 290 without HCC). The rs9514828 and rs12583006 polymorphisms were determined by allelic discrimination. RESULTS: The HCC group had significantly higher BAFF levels compared with the non-HCC group and healthy controls. Among the non-HCC group, the HBeAg-positive subgroup had higher BAFF levels compared with the HBeAg-negative subgroup. In the HCC group, high BAFF levels at initial presentation significantly correlated with alpha-fetoprotein levels, Child-Pugh classification, tumor size and BCLC stage. Multivariate analyses showed that elevated BAFF concentration (± 1,100 pg/ml) was a significant and independent prognostic factor of overall survival in patients with HCC (OR = 2.28, 95%CI: 1.07-4.87; P = 0.034). HCC patients with high BAFF levels (± 1,100 pg/ml) had a poorer median survival than those with low levels (P < 0.001, log-rank test). Regarding BAFF polymorphisms, the frequency of rs9514828 CT + TT genotypes was higher distributed in patients with chronic HBV infection compared with healthy controls (58.0% vs. 46.0%, P = 0.029). CONCLUSIONS: Our data demonstrate for the first time that elevated plasma BAFF levels at baseline exhibit clinical correlation in terms of disease severity and overall survival in HCC patients. Thus, plasma BAFF at initial diagnosis could serve as a prognostic marker for HBV-related HCC.

The Cytochrome P450 3A5 Non-Expressor Kidney Allograft as a Risk Factor for Calcineurin Inhibitor Nephrotoxicity.

BACKGROUND: Tacrolimus is mainly metabolized by cytochrome P450 3A5 (CYP3A5), which is expressed in the liver. However, CYP3A5 is also expressed in the kidney tissue and may contribute to local tacrolimus clearance in the kidney allograft. We aimed to evaluate the association between the allograft CYP3A5 genotype and transplant outcomes. METHODS: We conducted a retrospective cohort study at the King Chulalongkorn Memorial Hospital, Thailand, comparing 2 groups of donor and recipient CYP3A5 genotypes, the expressor (*1/*1 and *1/*3) and the non-expressor (*3/*3). The primary outcomes were allograft complications including calcineurin inhibitor (CNI) nephrotoxicity and acute rejection episode. RESULTS: Of the 50 enrolled patients, 21 donors were expressors and 29 donors were the non-expressors. Tacrolimus trough concentrations were similar between the 2 genotypes. The incidence of CNI nephrotoxicity was higher in recipients with non-expressor donor genotype compared with the expressor donor genotype (72.4 vs. 33.3%, p = 0.006). CNI nephrotoxicity incidence was not different when recipient's genotypes were compared. Multivariate analysis from Cox-regression showed a hazard ratio of 3.18 (p = 0.026) for CNI nephrotoxicity in the non-expressor compared with the expressor donor. The recipient CYP3A5 genotypes did not significantly contribute to CNI nephrotoxicity. Kaplan-Meier analysis demonstrated the lowest CNI nephrotoxicity-free survival in recipients with the expressor genotype who received allograft from the non-expressor donors (p = 0.005). CONCLUSION: In conclusion, our results suggest that donor CYP3A5 non-expressor genotype (*3/*3) is a risk for CNI nephrotoxicity.

Serum Wisteria floribunda agglutinin-positive Mac-2 binding protein level as a diagnostic marker of hepatitis B virus-related hepatocellular carcinoma.

AIM: Serum glycosylated Wisteria floribunda agglutinin-positive Mac-2 binding protein (WFA+ -M2BP) is a novel marker for staging liver fibrosis and predicting hepatocellular carcinoma (HCC) occurrence. This study aimed at evaluating the performance of WFA+ -M2BP in the diagnosis of HCC in patients with chronic hepatitis B virus (HBV) infection. METHODS: The WFA+ -M2BP levels were measured in stored samples collected at initial diagnosis of 150 patients with HBV-related HCC and 150 age- and gender-matched patients with non-malignant chronic HBV infection. RESULTS: Patients with HCC had higher levels of WFA+ -M2BP than those without HCC (3.9 [1.5-20.6] vs. 1.6 [0.4-9.3] cut-off index [COI], P < 0.001). In the HCC group, WFA+ -M2BP levels correlated with Child-Pugh classification but did not correlate with HBV markers, α-fetoprotein (AFP), or Barcelona Clinic Liver Cancer (BCLC) stage. The areas under the curve (AUROC) for differentiating HCC from non-HCC were 0.92 (95% confidence interval [CI], 0.89-0.95; P < 0.001) for WFA+ -M2BP, 0.90 (95% CI, 0.87-0.94; P < 0.001) for AFP, and 0.97 (95% CI, 0.95-0.98; P < 0.001) for the combination of both markers. At the optimal cut-off (2.4 COI), WFA+ -M2BP had sensitivity, specificity, and accuracy of 79.3%, 91.3%, and 85.3%, respectively. The WFA+ -M2BP marker was superior to AFP in differentiating early-stage HCC (BCLC stages 0 and A) from cirrhosis with AUROC of 0.80 (95% CI, 0.68-0.91; P < 0.001) and 0.73 (95% CI, 0.60-0.86; P = 0.002), respectively. By univariate analysis, elevated WFA+ -M2BP (≥4.0 COI) was correlated with poor overall survival in patients with HCC. CONCLUSIONS: Wisteria floribunda agglutinin-positive M2BP showed a better diagnostic performance than AFP in detecting early-stage HCC. Thus, WFA+ -M2BP level could represent a promising marker for early diagnosis of HCC in patients with chronic HBV infection.

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.

The first report of kidney transplantation in a human immunodeficiency virus-positive recipient in Thailand and literature review: Encouragement for developing countries in Southeast Asia.

Patients with human immunodeficiency virus infection are at risk of chronic kidney disease and end-stage renal disease. Human immunodeficiency virus infection impedes patients' accessibility to transplantation in Thailand and other developing countries in Southeast Asia, where the burdens of human immunodeficiency virus infection and chronic kidney disease are rapidly increasing. We report the successful kidney transplantation in a human immunodeficiency virus-positive recipient in Thailand and provide brief information about the current knowledge of human immunodeficiency virus medicine and transplantation that are needed for conducting kidney transplantations in such patients. Patient selection and evaluation, the choice of antiretroviral therapy, immunosuppressive regimens, and infectious complications are reviewed and discussed. The aim is to encourage kidney transplantation in end-stage renal disease patients with well-controlled human immunodeficiency virus infection, especially in countries where the prevalence of human immunodeficiency virus infection is high and the accessibility to transplantation is still limited.

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.

Diagnostic and prognostic roles of circulating miRNA-223-3p in hepatitis B virus-related hepatocellular carcinoma.

BACKGROUND: Circulating microRNAs (miRNAs) have been shown to dysregulate in many cancer types including hepatocellular carcinoma (HCC). The purpose of this study was to examine the potential diagnostic or prognostic roles of circulating miRNAs in patients with hepatitis B virus (HBV)-related HCC. METHODS: Paired cancerous and adjacent non-cancerous liver tissue specimens of patients with HBV-related HCC were used as a discovery set for screening 800 miRNAs by a Nanostring quantitative assay. Differentially expressed miRNAs were then examined by SYBR green quantitative RT-PCR in a validation cohort of serum samples obtained from 70 patients with HBV-related HCC, 70 HBV patients without HCC and 50 healthy controls. RESULTS: The discovery set identified miR-223-3p, miR-199a-5p and miR-451a significantly lower expressed in cancerous tissues compared with non-cancerous tissues. In the validated cohort, circulating miR-223-3p levels were significantly lower in the HCC group compared with the other groups. The combined use of serum alpha-fetoprotein and miR-223-3p displayed high sensitivity for detecting early HCC (85%) and intermediate/advanced stage HCC (100%). Additionally, serum miR-223-3p had a negative correlation with tumor size and BCLC stage. On multivariate analysis, serum miR-223-3p was identified as an independent prognostic factor of overall survival in patients with HCC. In contrast, circulating miRNA-199a-5p and miR-451a did not show any clinical benefit for the diagnosis and prognostic prediction of HCC. CONCLUSIONS: Our results demonstrated that miR-223-3p was differentially expressed in cancerous compared with paired adjacent non-cancerous tissues. In addition, circulating miRNA-223-3p could represent a novel diagnostic and prognostic marker for patients with HBV-related HCC.

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.

Partial segment-IV/V liver resection facilitates the repair of complicated bile duct injury.

The ability to perform a technically perfect anastomosis remains the key to success in bile duct repair. This report describes our technique in facilitating the performance of a good surgical anastomosis for difficult bile duct repair. In the present study are presented 3 cases of bile duct repair for a Strasberg type-E3 stricture, a Strasberg type-E4 fistula and an anastomotic stricture of a previously performed choledochojejunostomy for the correction of bile duct injury. The approach was to perform partial resection of the lower part of segments IV and V. The hepatoduodenal ligament was not dissected. The anterior surface of the bile duct was utilized to perform Roux-en-Y hepaticojejunostomy. Operative times ranged from 4 to 5 hours, and Pringle times 15 to 25 minutes. There was no vascular injury. We were able to perform wide anastomoses, facilitated by excellent exposure of the hilar plate. There was no any complication. Partial resection of the hepatic segments IV-V provides excellent exposure of the hilar plate. The risk of vascular injury was minimized by avoiding dissection of the hepatoduodenal ligament. It is believe this technique may offer a superior approach to difficult repair of complicated bile duct injury.

Plasmapheresis Reduces Mycophenolic Acid Concentration: A Study of Full AUC0-12 in Kidney Transplant Recipients.

BACKGROUND: Mycophenolic acid (MPA), a crucial immunosuppressive drug, and plasmapheresis, an effective immunoreduction method, are simultaneously used for the management of various immune-related diseases, including kidney transplantation. While plasmapheresis has been proven efficient in removing many substances from the blood, its effect on MPA plasma levels remains unestablished. OBJECTIVES: To evaluate the full pharmacokinetics of MPA by measuring the area under the time-concentration curve (AUC0-12), which is the best indicator for MPA treatment monitoring after each plasmapheresis session, and to compare the AUC0-12 measurements on the day with and on the day without plasmapheresis. METHODS: A cross-sectional study was conducted in kidney transplantation recipients who were taking a twice-daily oral dose of mycophenolate mofetil (MMF, Cellcept®) and undergoing plasmapheresis at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, during January 2018 and January 2019. The MPA levels were measured by an enzymatic method (Roche diagnostic®) 0, 1/2, 1, 2, 3, 4, 6, 8, and 12 h after MMF administration, for AUC0-12 calculation on the day with and on the day without plasmapheresis sessions. Plasmapheresis was started within 4 h after administering the oral morning dose of MMF. Our primary outcome was the difference of AUC0-12 between the day with and the day without plasmapheresis. RESULTS: Forty complete AUC measurements included 20 measurements on the plasmapheresis day and other 20 measurements on the day without plasmapheresis in six kidney transplant patients. The mean age of the patients was 56.2 ± 20.7 years. All patients had received 1000 mg/day of MMF for at least 72 h before undergoing 3.5 ± 1.2 plasmapheresis sessions. The mean AUC on the day with plasmapheresis was lower than that on the day without plasmapheresis (28.22 ± 8.21 vs. 36.79 ± 10.29 mg × h/L, p = 0.001), and the percentage of AUC reduction was 19.49 ± 24.83%. This was mainly the result of a decrease in AUC0-4 of MPA (23.96 ± 28.12% reduction). CONCLUSIONS: Plasmapheresis significantly reduces the level of full AUC0-12 of MPA. The present study is the first to measure the full AUC0-12 in MPA-treated patients undergoing plasmapheresis. Our study suggests that a supplementary dose of MPA is necessary for patients undergoing plasmapheresis.

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.

Increased ATG5-ATG12 in hepatitis B virus-associated hepatocellular carcinoma and their role in apoptosis.

AIM: To investigate autophagy-related genes, particularly ATG12, in apoptosis and cell cycle in hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) and non-HBV-HCC cell lines. METHODS: The expression of autophagy-related genes in HBV-associated hepatocellular carcinoma and non-HBV-HCC cell lines and human liver tissues was examined by quantitative real-time reverse transcriptase-polymerase chain reaction (qRT-PCR) and western blotting. The silencing of target genes was used to examine the function of various genes in apoptosis and cell cycle progression. RESULTS: The expression of autophagy related genes ATG5, ATG12, ATG9A and ATG4B expression was analyzed in HepG2.2.15 cells and compared with HepG2 and THLE cells. We found that ATG5 and ATG12 mRNA expression was significantly increased in HepG2.2.15 cells compared to HepG2 cells (P < 0.005). Moreover, ATG5-ATG12 protein levels were increased in tumor liver tissues compared to adjacent non-tumor tissues mainly from HCC patients with HBV infection. We also analyzed the function of ATG12 in cell apoptosis and cell cycle progression. The percentage of apoptotic cells increased by 11.4% in ATG12-silenced HepG2.2.15 cells (P < 0.005) but did not change in ATG12-silenced HepG2 cells under starvation with Earle's balanced salt solution. However, the combination blockade of Notch signaling and ATG12 decreased the apoptotic rate of HepG2.2.15 cells from 55.6% to 50.4% (P < 0.05). CONCLUSION: ATG12 is important for HBV-associated apoptosis and a potential drug target for HBV-HCC. Combination inhibition of ATG12/Notch signaling had no additional effect on HepG2.2.15 apoptosis.

Acute mesenteric ischemia: still high mortality rate in the era of 24-hour availability of angiography.

BACKGROUND: Acute mesenteric ischemia (AMI) is a serious condition with high mortality rate due to difficult and late diagnosis. Early and aggressive evaluation in high risk patients by mesenteric angiography is the key to the reduction in mortality rate. However; many physicians hesitated to perform it because of its availability, the risk of complications and high negative results. This study reviewed outcome of AMI in term of mortality rate, factors associated with mortality and the rate of angiography in high risk patients. MATERIAL AND METHOD: The clinical data of the patients who were diagnosed as AMI were retrospectively reviewed. The clinical outcome was recorded and the factors associated with mortality were analysed. RESULTS: Thirty-five patients were enrolled into this study during 5 years. The mortality rate was 74.3%. There were 22 high risk patients for AMI. The rate of angiography performed in this group was 4.5% (1/22). The factors associated with mortality were age more than 60 years, patients with peritonitis, hypotension, arterial cause, time interval between admission and operation or treatment more than 24 hours, bowel gangrene >100 cms. However all these factors were not statistically significant. CONCLUSION: The mortality rate of AMI is still high even at the tertiary hospital where the angiography is available 24 hours. To decrease the mortality rate, the physicians must have the high index of suspicion in high risk patients and do not hesitate to perform early mesenteric angiography.

Risk factors associated with major intraoperative blood loss in hepatic resection for hepatobiliary tumor.

BACKGROUND AND PURPOSE: Hepatic resection is the mainstay treatment of hepatobiliary tumor Nowadays, mortality is less than 6%. However, morbidity is still high. Bleeding is one of the most common problems during hepatic resection which can sometimes lead to catastrophe. The purpose of the present study was to investigate the risk factors associated with major blood loss during hepatic resection for hepatobiliary tumor. MATERIAL AND METHOD: A total of 69 consecutive patients who underwent elective hepatic resection for hepatobiliary tumor from May 2002 to April 2004 were enrolled into this retrospective study. The Patients were divided into 2 groups(group I and II) according to the intraoperative blood loss. Patients who had a blood loss of more than 1000 ml were defined as the major blood loss group(group I). Thirteen variable factors were analyzed to determine the risk of major intraoperative blood loss. Operative outcomes between the two groups were also compared. RESULTS: Of the sixty-nine patients, 36 patients were in group I and 33 patients were in group II. 75% of the patients in group I and 36.4% of the patients in group II were transfused. Median blood transfusion in group I and II were 3 and 0 units of packed red cell. Univariate analysis showed tumor size, extent of hepatic resection, tumor pathology and operative time were factors affecting major intraoperative blood loss. However, multivariate analysis showed only operative time and tumor size to be independent risk factors. Patients in group I had higher surgical morbidity and prolonged hospital stay compared with patients in group II. CONCLUSION: Blood loss is still a major concern in performing hepatic resection. From the present study, tumor size and operative time are the independent factors affecting major intraoperative blood loss. Proper screening or a surveillance program may enhance the chance to find small tumors. Refined operative techniques such as anterior approach and liver hanging would facilitate resection for large right sided tumors.

Preoperative portal vein embolization in hepatobiliary tract malignancy: an experience at King Chulalongkorn Memorial Hospital.

BACKGROUND: Major hepatic resections are increasingly performed for both primary and secondary liver cancers nowadays. However, morbidity from these operations is still high. One of the dreadful complications, sometimes lead to fatality, is postoperative liver failure. There are many factors which are associated with this complication such as chronic liver disease, low residual liver volume after resection. Portal vein embolization (PVE) is the procedure which increases the liver volume of the non-embolized lobe. Now, PVE has gained acceptance in many centers to overcome or reduce this complication. This report described the authors' experiences of PVE since 2001 at King Chulalongkorn Memorial Hospital. MATERIAL AND METHOD: The records of 10 patients who had PVE were reviewed CT volumetry of the liver was done before and after procedure. The authors calculated future liver remnant from CT volumetry and compared this volume to standard liver volume. The postoperative complications and hospital courses of these patients were also recorded. RESULTS: Mean growth of future liver remnant (FLR) ratio after PVE was 13.7 +/- 6.2% (median 13, range 4-25). There was no major complication after PVE. Six patients underwent liver resection and there was no major complication or mortality. No one had persistent hyperbilirubinemia 2 weeks after operation. CONCLUSION: The PVE is the useful and safe optional procedure to increase future liver remnant volume. It not only reduces the postoperative liver failure but increases the chance for curative resection.

A germline mutation in a Thai family with familial multiple endocrine neoplasia type 1.

Multiple endocrine neoplasia type 1, caused by the mutation in the MEN1 gene, is an autosomal dominant disorder with over 95% penetrance characterized by hyperparathyroidism, pancreatic endocrine tumor and pituitary tumor. The authors performed a molecular analysis to identify a mutation in a Thai man with MEN1. He was found to be heterozygous for IVS6 + 1G to A. Two of his three children were also found to carry this mutation. The newly available genetic test for patients with MEN1 in Thailand makes it possible to accurately DNA-based diagnose clinically suspected individuals and their presymptomatic members, which has important therapeutic impacts on them.

Minimally invasive surgery training in soft cadaver (MIST-SC).

OBJECTIVES: The purpose of this study was to evaluate the surgical anatomy, tissue plane, organ consistency of soft cadaver and the possibility of minimally invasive surgery training in soft cadaver. SETTING: Surgical Training Center. Department of Anatomy and Department of Surgery Faculty of Medicine, Chulalongkorn University. DESIGN: Prospective descriptive study. MATERIAL AND METHOD: 2 soft cadavers were scheduled for fully laparoscopic surgery in upper gastrointestinal, colorectal, hepatopancreatobiliary and solid organs surgery. All the procedures were performed by the experienced surgical staffs and assisted by surgical staffs and/or surgical residents. The surgical anatomy, tissue plane, organ consistency and the satisfactory in performing the procedures were recorded for evaluation. RESULTS: The surgical anatomy, the tissue consistency the anatomical plane were very well preserved with mean score of 4.72 +/- 0.45. All the surgeons were satisfied with the findings, the mean score was 4.97 +/- 0.18. All the plan procedures were completely performed with great satisfactory results. CONCLUSION: The Minimally Invasive Surgery Training in Soft Cadaver (MIST-SC) was feasible with great satisfactory. This successful integration of basic and advanced laparoscopic procedures into the soft cadaver setting would be the next step in evolution of MIS training.

Outcome of colorectal liver metastases.

OBJECTIVE: To determine the median survival of colorectal liver metastatic (CRLM) patients treated at King Chulalongkorn Memorial Hospital over the past 10 years and to determine the outcome of the various treatment modalities (surgery, chemotherapy and supportive treatment). MATERIAL AND METHOD: Between January, 1992 and December, 2001, 86 consecutive patients were recorded. Of whom 26 (30.23%) received liver resection, 39 (45.34%) received chemotherapy and 21 (24.41%) received supportive treatment. All the patients were followed up to December 31, 2001 or death. Survival was calculated by Kaplan-Meier method and studied for statistical differences between various treatment groups with Cox regression model. The 95% confidence intervals for median assessment were determined. RESULTS: Overall survival of CRLM patients was 18 months. Significant differences in survival were seen among the three groups of patients. Median survival was 33 months in the liver resection group, 17 months in the chemotherapy group and 5 months in the supportive treatment group. Three-year survival in the liver resection group was 23% while it was 7.6% in the chemotherapy group. Type of treatment, primary tumor staging and extrahepatic metastasis were the three independent determinant factors of survival. CONCLUSION: Survival of patients with colorectal liver metastases depends on the type of treatment. Liver resection is the best treatment which offers long term survival to the patients in selected cases.

Result of orthotopic liver transplantation at King Chulalongkorn Memorial Hospital: the first series from Thailand.

Liver transplantation is one of the best treatments for advanced liver disease since it can prolong the patient's survival. In Thailand, the first liver transplantation was performed in 1987 at King Chulalongkorn Memorial Hospital. Up till now the authors have transplanted the most in Thailand, having done more than 30 cases. From 1997 to 2002, there were 20 cases of liver transplantation and this is the result presented. The authors classified the patients into 2 groups, according to primary indications for transplantation. Patients with cirrhosis were included in group I and patients with hepatocellular carcinoma were included in group II. The one year survival in group I and II was 64 per cent and 29 per cent respectively. Mortality rate in the cirrhotic group was high during the first 3 months post transplant. The reason for a high mortality rate in the hepatocellular carcinoma group may be secondary to the advanced stage of cancer and the poor condition of the patients. However, the acute rejection rate in the present series of 25 per cent is relatively low compared to other series and this may need further study. The one year survival rate in patients who received a new liver from 1997 to 1999 compared to 2000-2002 was 33 per cent and 54 per cent respectively. This showed an improvement in the result of liver transplantation in Thailand. In conclusion, this report showed a satisfactory result of liver transplantation. The main problem with liver transplantation in Thailand is that potential donors do not understand the problems which leads to few donors. There is also a shortage of skilled personnel, budget, and the appropriate instruments.