Chemotherapy and repeat resection abrogate the prognostic value of neutrophil lymphocyte ratio in colorectal liver metastases.

BACKGROUND: Evolution in surgical and oncological management of CRLM has called into question the utility of clinical risk scores. We sought to establish if neutrophil lymphocyte ratio (NLR) has a prognostic role in this patient cohort. METHODS: From 2005 to 2015,379 hepatectomies were performed for CRLM, 322 underwent index hepatectomy, 57 s hepatectomies were performed. Clinicopathological data were obtained from a prospectively maintained database. Variables associated with longterm survival following index and second hepatectomy were identified by Cox regression analyses and reviewed along with 30-day post-operative morbidity and mortality. RESULTS: Following index hepatectomy 1-,3-and 5-year survival was 90.7%, 68.1% and 48.6%. Major resection, positive margins and >5 tumours were negatively associated with survival. Those with elevated NLR(>5) had a median survival of 55 months, compared to 70 months with lower NLR(p = 0.027). Following neoadjuvant chemotherapy, no association between NLR and survival was demonstrated (p = 0.93). Furthermore, NLR >5 had no impact on prognosis following repeat hepatectomy. Tumour diameter >5 cm (p = 0.04) was the sole predictor of poorer survival (p = 0.049). CONCLUSION: Despite elevated NLR correlating with shorter survival following index hepatectomy, this effect is negated by neoadjuvant chemotherapy and second hepatectomy for recurrent disease. This data would not support the use of NLR in the preoperative decision algorithm for patients with CRLM.

Depleted polymorphonuclear leukocytes in human metastatic liver reflect an altered immune microenvironment associated with recurrent metastasis.

BACKGROUND: Hepatic immunity, normally protective against neoplasia, is subverted in colorectal liver metastasis (CRLM). Here, we compare the inflammatory microenvironment of CRLM-bearing liver tissue to donor liver. METHODS: Twenty-five patients undergoing resection for CRLM were recruited, 13 of whom developed intrahepatic recurrence within 18 months. Biopsies were obtained from tumour and normal liver tissue adjacent to and distal from, the tumour. Donor liver biopsies were obtained during transplantation. Biopsies were cultured and conditioned media (CM) screened for 102 inflammatory mediators. Twelve of these were validated by Luminex assay. Transwell assays measured cancer cell chemotaxis. Polymorphonuclear leukocytes (PMN) and lymphocytes were quantified in H&E sections. RESULTS: Fewer periportal tissue-resident PMN were present in metastatic liver compared to donor liver. Patients with the fewest PMN in liver tissue distal to their tumour had a shorter time to intrahepatic recurrence (P < 0.001). IL-6, CXCL1, CXCL5, G-CSF, GM-CSF, VEGF, LIF, and CCL3 were higher in liver-bearing CRLM compared to donor tissue. Consequently, cancer cells migrated equally towards CM of all regions of metastatic liver but not towards donor liver CM. CONCLUSIONS: The local inflammatory environment may affect both immune cell infiltration and cancer cell migration contributing to recurrence following resection for CRLM.

Multivisceral Resection for Locally Invasive Colorectal Liver Metastases: Outcomes of a Matched Cohort Analysis.

Local invasion of adjacent viscera by colorectal liver metastases (CRLM) is no longer considered an absolute contraindication to curative hepatic resection. A growing number of observational analyses have illustrated the feasibility of such resections; however, the evidence base is at best heterogeneous with a lack of evidence comparing similar patient groups. We aimed to evaluate the outcomes of hepatectomy for CRLM when combined with other viscera and compare to a matched cohort of isolated hepatic resections. METHODS: From 2005 to 2015, 523 patients underwent hepatic resection for CRLM at our institution, 19 of whom underwent hepatectomy with extrahepatic resection. A 3: 1 matched cohort analysis was performed between those who underwent isolated hepatectomy (control group) and those who underwent hepatectomy with extrahepatic resection (combined group). Clinicopathological data were reviewed along with 30-day postoperative morbidity and mortality. Furthermore, overall survival for the multivisceral cohort was compared to all other isolated hepatectomies over the same time period. RESULTS: Nineteen patients underwent liver resection accompanied by either/or diaphragmatic resection (n = 13), major vein resection and reconstruction (n = 5), and visceral resection (n = 3). Maximum tumor size was significantly larger in the combined group (60.58 vs. 15.34 mm p < 0.0001). Postoperative morbidity was similar in both groups (p = 0.41). Following multivisceral resection, 1-, 3- and 5-year survival rates were 75, 56.6, and 25.7% respectively. Overall survival showed no significant difference between combined and control groups (p = 0.78). Similarly, when compared to the total cohort of isolated liver resections (n = 504), no significant difference in overall mortality was noted. CONCLUSION: In patients presenting with concomitant CRLM and extrahepatic extension where R0 margins can be achieved, this present study supports the rationale to proceed to -surgery with comparable morbidity and mortality rates to -isolated hepatectomy.

Osteoclastic-Type Giant Cell Tumours of the Pancreas: A Homogenous Series of Rare Tumours Diagnosed by Endoscopic Ultrasound.

BACKGROUND: Giant cell tumors (GCT) of the pancreas are a rare form of pancreatic cancer. Although data are limited, clinical outcomes appear to depend largely on histological subtype with osteoclastic tumors carrying a better prognosis. We report on a homogenous series of patients with osteoclastic-type GCTs of the pancreas presenting to a national pancreatico-biliary gastrointestinal oncology center. METHODS: Patients underwent endoscopic, radiological and histopathological assessments. Data were collected in relation to consecutive patients presenting with osteoclastic-type tumors of the pancreas and analyzed with survival as a primary end point. RESULTS: Four patients were treated over a 4-year period. Median age was 77 years with equal gender distribution. Median tumor size was 42 mm. Histology was osteoclast-type giant cells in all 4 patients. Two patients underwent surgery with curative intent. Median overall survival was 13.1 months. CONCLUSION: This is the largest reported series of osteoclast-type histology in GCTs of the pancreas.

Radiofrequency ablation for neuroendocrine liver metastases: a systematic review.

To determine the efficacy of radiofrequency (RF) ablation in neuroendocrine tumor (NET) liver metastases. A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight studies were included (N = 301). Twenty-six percent of RF ablation procedures were percutaneous (n = 156), with the remainder conducted at surgery. Forty-eight percent of patients had a concomitant liver resection. Fifty-four percent of patients presented with symptoms, with 92% reporting symptom improvement following RF ablation (alone or in combination with surgery). The median duration of symptom improvement was 14-27 months. However, recurrence was common (63%-87%). RF ablation can provide symptomatic relief in NET liver metastases alone or in combination with surgery.

Neoadjuvant chemoradiotherapy followed by liver transplantation for unresectable cholangiocarcinoma: a single-centre national experience.

BACKGROUND: Unresectable cholangiocarcinoma (CCA) has a dismal prognosis. Initial studies of orthotopic liver transplantation (OLT) alone for CCA yielded disappointing outcomes. The Mayo Clinic demonstrated long-term survival using neoadjuvant chemoradiotherapy followed by OLT in selected patients with unresectable CCA. This study reports the Irish National Liver Transplant Programme experience of neoadjuvant therapy and OLT for unresectable CCA. MATERIALS AND METHODS: Twenty-seven patients with CCA were selected for neoadjuvant chemoradiotherapy in a single centre from October 2004 to September 2011. Patients were given brachytherapy, external beam radiotherapy and 5-fluorouracil (5-Fu), followed by liver transplantation if progression free (20 patients). RESULTS: Twenty progression-free patients after neoadjuvant therapy underwent OLT. Hospital mortality was 20%. Of the 16 patients who left hospital, survival rates were 94% and 61% at 1 and 4 years. Seven patients developed recurrent disease and died at intervals of 10-58 months after OLT, whereas 9 are disease free with a median follow-up of 37 months (18-76). Predictors of disease recurrence were a tumour in explant specimen and high CA 19.9 levels. DISCUSSION: In selected patients with unresectable CCA, long-term survival can be achieved using neoadjuvant chemoradiotherapy and OLT although short-term mortality is high. Prospective international registries may aid patient selection and refinement of neoadjuvant regimens.

Incidence and risk factors of delirium in patients post pancreaticoduodenectomy.

BACKGROUND: Post-operative delirium is an important and common complication of major abdominal surgery characterized by acute confusion with fluctuating consciousness. The aim of this study was to establish the incidence of post-operative delirium in patients undergoing a pancreaticoduodenectomy and to determine the risk factors for its development. METHODS: From a prospectively maintained database, a retrospective cohort analysis was performed of 50 consecutive patients who underwent a pancreaticoduodenectomy at the National Surgical Centre for Pancreatic Cancer in St. Vincent's University Hospital, Dublin and whose entire post-operative stay was in this institution, between July 2011 and December 2012. Two independent medical practitioners assessed all data and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual Disorder (DSM), fourth edition. Univariate and multivariate analyses were performed. RESULTS: Seven patients (14%) developed post-operative delirium. The median onset was on the second post-operative day. Older age was predictive of an increased risk of delirium post-operatively. Those who developed delirium had a significantly increased length of stay (LOS) as well as a significantly increased risk of developing at least a grade 3 complication (Clavien-Dindo classification). CONCLUSION: This study demonstrates that post-operative delirium is associated with a more complicated recovery after a pancreaticoduodenectomy and that older age is independently predictive of its development. Focused screening may allow targeted preventative strategies to be used in the peri-operative period to reduce complications and costs associated with delirium.

Hepatic resection for breast cancer related liver metastases: A single institution experience.

BACKGROUND & OBJECTIVE: Liver resection for breast cancer liver metastases is becoming a more widely accepted therapeutic option for selected groups of patients. The aim of this study was to describe the outcomes of patients undergoing liver resection for breast cancer-related liver metastases and identify any variables associated with recurrence or survival. METHODS: A retrospective review of a prospectively maintained database was undertaken for the 12 year period between 2009 and 2021. Clinicopathological, treatment, intraoperative, recurrence, survival and follow-up data were collected on all patients. Kaplan-Meier methods, the log-rank test and Cox proportional hazards regression analysis were used to identify variables that were associated with recurrence and survival. RESULTS: A total of 20 patients underwent 21 liver resections over the 12-year period. There were no deaths within 30 days of surgery and an operative morbidity occurred in 23.8% of cases. The median local recurrence free survival and disease free survival times were both 50 months, while the 5 year overall survival rate was 65%. The presence of extrahepatic metastases were associated with a decreased time to local recurrence (p < 0.01) and worse overall survival (p = 0.02). CONCLUSIONS: This study has demonstrated that liver resection for breast cancer-related liver metastases is feasible, safe and associated with prolonged disease free and overall survival in selected patients. It is likely that this option will be offered to more patients going forward, however, the difficulty lies in selecting out those who will benefit from liver resection particularly given the increasing number of systemic treatments and local ablative methods available that offer good long-term results.

Routine Endoscopy After Acute Sigmoid Diverticulitis: Would a Sigmoidoscopy be Sufficient?

BACKGROUND:  Current guidelines suggest that patients should undergo colonoscopy after CT confirmed acute diverticulitis to outrule colorectal cancer (CRC). The aim of this study was to determine if flexible sigmoidoscopy (FS) could be a viable alternative to full colonoscopy following acute sigmoid diverticulitis. METHODS:  A retrospective study of 271 patients was performed who were diagnosed with acute sigmoid diverticulitis by CT and subsequently underwent full colonoscopy. Medical records, CT reports, endoscopy reports, and histopathological reports were reviewed. RESULTS:  Sigmoid diverticulosis was confirmed on colonoscopy in all patients. No colorectal malignancies were detected. Adenomatous polyps were found in 16 (5.9%) patients, of which three had polyps detected beyond the sigmoid colon. The overall proportion of abnormalities found beyond the sigmoid colon was 1.1% (n=3). CONCLUSION:  The detection of CRC cancer in patients undergoing full colonoscopy following an episode of acute sigmoid diverticulitis is rare. Despite this, current guidelines still advocate for endoscopy due to the potentially serious consequences of a missed malignancy. However, given that the area of concern in these cases is the sigmoid colon, FS may be a feasible means of outruling malignancy in the absence of red flag features that would necessitate a full colonoscopy. Our results support this approach, with no CRC detected and a polyp detection rate equivalent to that of the general population. This offers numerous advantages to a full colonoscopy for the patient and health service by being a quicker, cheaper, safer procedure without the need for full bowel preparation or IV sedation.

A Liver's Iliad: Liver Graft Retransplant to a Second Recipient After Brain Death in a First Recipient.

With the current increased incidence of cirrhosis, the demand for liver transplant continues to grow. Here, we performed a systematic review to assess the feasibility, safety, and long-term outcomes of reused liver grafts for expansion of the donor pool. Our search identified 19 studies, including 36 patients plus 1 patient from our own institution. Ten studies were single case reports, 4 were case series, 4 were letters to the editor, and 1 was a literature review and also included a case report. Our patient presented with intentional acetaminophen overdose, received a transplant from a brain dead donor, and was confirmed brain dead 12 days posttransplant. The second recipient, who had alcoholrelated liver disease cirrhosis, underwent orthotopic liver transplant with the reused liver and was discharged from the hospital after an uneventful postoperative course. Among the 19 studies, all donors had confirmed brain death and all transplants included the whole liver, except for 2 cases of auxiliary liver grafts (reduced liver transplant) and 1 case of extended right living-donor liver graft (donor and recipient being related sisters). Overall, among first recipients, the most frequent cause of liver disease was acetaminophen overdose followed by alcohol-related liver disease cirrhosis. There were 2 cases of retransplant. Among second recipients, hepatocellular carcinoma was the most frequent cause of liver disease followed by alcohol-related liver disease cirrhosis. We found that functional outcomes with these grafts were comparable to outcomes with grafts from conventional donors; in the absence of other contraindications, we suggest that, not only for liver transplant but for other organs, these reused grafts can be used for those awaiting transplantation. Because the ability to reuse grafts is an infrequent condition, it would be difficult to generally recommend this technique; however, on a case-by-case basis, this source could expand the donor pool.

Laparoscopic totally extraperitoneal hernia repair performed by surgical trainees: overcoming the learning curve.

BACKGROUND: Surgical trainees struggle to obtain experience in laparoscopic inguinal hernia repair (LIHR) due to a perceived steep learning curve. The purpose of this study was to compare outcomes in totally extraperitoneal (TEP) repair performed by surgical consultants and trainees under supervision as part of a standardised training regimen to assess the safety of residency training in this technique. METHODS: A retrospective review of patients managed by TEP repair by either a consultant or a supervised trainee was performed. Demographic, perioperative and postoperative data were collected and compared. All trainees underwent a standardised approach to teaching TEP repair. RESULTS: Trainees performed 133 procedures and consultants performed 121 procedures. Estimated blood loss was minimal in both cohorts. A significant difference was noted in mean operating time between consultants and trainees (33 vs. 50 min). However, it was also observed that the trainee mean operating time reduced significantly with experience (from 61 to 42 min). No statistically significant difference was demonstrated in postoperative complications, recurrence rate or length of stay. All trainees achieved the ability to complete a laparoscopic TEP repair under unscrubbed consultant supervision during a 1-year placement. CONCLUSION: With senior supervision and in the presence of a structured training regimen, trainees can safely and effectively perform LIHR, progressing to performing the procedure under unscrubbed consultant supervision. This is valuable information that can serve to inform the structure and direction of surgical training programmes as the ability to offer LIHR is increasingly becoming an expectation of consultant surgeons.

Life-Threatening Intraparenchymal Hemorrhage of Steroid-Induced Hepatic Adenomas in a Healthy Man.

Hepatocellular adenomas are uncommon benign epithelial tumors of the liver that are associated with several risk factors such as anabolic androgens and oral contraceptive pills. They may present as incidental findings, with abdominal pain or hemorrhage. This case report details the presentation and management of a life-threatening hepatocellular adenomas hemorrhage in a seemingly healthy 28-year-old man. After initial conservative management, a clinical deterioration prompted urgent reevaluation and successful embolization of the liver through transarterial embolization. As oral contraceptive pills use and anabolic steroid abuse have become more prevalent in recent decades, we may begin to see more of these presentations.

Diagnostic Inaccuracies of Barrett's Oesophagus on Gastroscopy: Are We Performing Unnecessary Surveillance?

Background It is common for patients to enter Barrett's oesophagus (BO) surveillance based on endoscopic appearances before the diagnosis is histologically confirmed. We set out to review this practice by establishing the accuracy of endoscopic diagnoses of BO. Methods All gastroscopy reports in which a diagnosis of BO was recorded were reviewed over one year. These were compared to the histopathological reports to assess diagnostic accuracy. Results BO was diagnosed in 84 procedures. This diagnosis was incorrect according to histology in 42.9% (n=36) of cases. Diagnostic accuracy was higher with gastroenterologists (38.8% incorrect, n=21) compared to surgeons (50% incorrect, n=15). Diagnostic accuracy was higher with consultants (34.9% incorrect, n=22) compared to registrars (66.7% incorrect, n=14). The dose of sedation used had no impact on accuracy. Unnecessary surveillance was booked in 36.1% (n=13) of cases. Conclusion It is insufficient to rely on endoscopic appearances alone to diagnose BO, irrespective of speciality or experience. The diagnosis should only be made after reviewing the histopathology report. This can eliminate unnecessary repeat endoscopy procedures, sparing patients from unjustifiable risk and helping to cut down on long waiting lists in endoscopy departments. The implementation of the Prague classification and Seattle protocol can improve diagnostic accuracy.

The dilemma of the duplicated cystic duct: a case report.

We present a rare case of a duplicated cystic duct encountered during an elective laparoscopic cholecystectomy in a patient with biliary colic. Prompt recognition of an intraoperative bile leak followed by thorough examination and recognition of the source allowed for timely and appropriate management of the affected patient with a satisfactory post-operative outcome. Our case is unique by the lack of availability of intraoperative cholangiogram at the time of surgery, which posed a significant diagnostic and therapeutic challenge, and by how aberrant anatomy was confirmed intraoperatively by reviewing prior cardiac magnetic resonance imaging. Unremarkable preoperative imaging does not rule out the presence of abnormal anatomy. Early involvement of a specialist hepatobiliary surgeon is essential in an unexplained bile leak, with a low threshold in converting to an open procedure if there is difficulty in clearly deciphering anatomy.

Neoadjuvant Chemoradiotherapy and Liver Transplantation for Unresectable Hilar Cholangiocarcinoma: The Irish Experience of the Mayo Protocol.

BACKGROUND: Pioneered by the Mayo Clinic, multimodal therapy with neoadjuvant chemoradiotherapy and orthotopic liver transplant has emerged as a promising option for unresectable hilar cholangiocarcinoma (hCCA). This study reports the experience of the Irish National Liver Transplant Programme with the Mayo Protocol. METHODS: All patients diagnosed with unresectable hCCA between 2004 and 2016, who were eligible for the treatment protocol, were prospectively studied. RESULTS: Thirty-seven patients commenced chemoradiotherapy. Of those, 11 were excluded due to disease progression and 26 proceeded to liver transplantation. There were 24 males, the median age was 49, and 88% had underlying primary sclerosing cholangitis. R0 and pathologic complete response rates were 96% and 62%, respectively. Overall median survival was 53 months and 1-, 3-, and 5-year survival was 81%, 69%, and 55%, respectively. The median survival of patients achieving a pathologic complete response was 83.8 months compared with 20.9 months in the group with residual disease (P = 0.036). Six patients (23%) developed disease recurrence. Among the patients who developed metastatic disease during neoadjuvant treatment, median survival was 10.5 months compared with 53 months in patients who proceeded to transplant (P < 0.001). CONCLUSIONS: Neoadjuvant chemoradiotherapy followed by liver transplantation substantially increases the survival of patients with unresectable hCCA. Achieving a pathologic complete response confers a significant survival benefit.

Quality of life after iatrogenic bile duct injury: a case control study.

OBJECTIVE: To compare quality of life (QOL) of patients following iatrogenic bile duct injuries (BDI) to matched controls. SUMMARY BACKGROUND DATA: BDI complicate approximately 0.3% of all cholecystectomy procedures. The literature regarding impact on quality of life is conflicted as assessment using clinical determinants alone is insufficient. METHODS: The medical outcomes study short form 36 (SF-36), a sensitive tool for quantification of life quality outcome, was used. The study group of iatrogenic BDI was compared with an age- and sex-matched group who underwent uncomplicated cholecystectomy. Telephone questionnaire using the SF-36 quality of life tool was administered to both groups at a median postoperative time of 12 years 8 months (range, 2 months -20 years). RESULTS: Seventy-eight patients were referred with BDI but due to mortality (n = 10) and unavailability (n = 6) 62 participated. The age- and sex-matched control cohort had undergone uncomplicated cholecystectomy (n = 62). Comparison between groups revealed that 7 of 8 variables examined were statistically similar to those of the control group (physical functioning, role physical, bodily pain, general health perceptions, vitality and social functioning, and mental health index). Mean role emotional scores were slightly worse in the BDI group (46 vs. 50) but the significance was borderline (P = 0.045). Subgroup analysis by method of intervention for BDI did not demonstrate significant differences. CONCLUSION: Quality of life of surviving patients following BDI compares favorably to that after uncomplicated laparoscopic cholecystectomy.

Lower expression of Nrf2 mRNA in older donor livers: a possible contributor to increased ischemia-reperfusion injury?

BACKGROUND: The cellular mechanisms involved in mediating cytoprotection against ischemia-reperfusion (IR) injury are not well understood. In animal models, NF-E2-related factor-2 (Nrf2) protects against IR injury by transcriptional activation of phase II antioxidants. Here, we investigate how the expression of Nrf2 mRNA in human donor livers in the setting of liver transplantation (LT) correlates with the histological damage associated with IR injury and whether or not this influences the outcome of LT. METHODS: Pairs of biopsies were acquired from 14 donor livers; the first biopsy of each pair was taken at the start of the retrieval operation, prior to the IR phase of LT and the second at the end of transplantation. RNA was extracted from snap frozen tissue and cDNA was prepared. Nrf2 mRNA expression was determined using real-time polymerase chain reaction (PCR). The modified Suzuki scoring system was used for histological grading of IR injury and relevant donor, recipient, and after LT clinical data were compiled. RESULTS: Nrf2 expression was observed in all biopsies, both before and after IR. Some donor organs had greater expression of Nrf2 mRNA before IR injury, and these organs had lower Suzuki scores and better liver functions (ALT) after LT. Donors of livers with greater Nrf2 levels were significantly younger (40.5 yrs, range 28-53 yrs) than those with low Nrf2 levels (55.5 yrs, range 48-61 yrs), P<0.05. CONCLUSION: Livers from older donors have lower levels of Nrf2 perhaps exposing these organs to more IR-related damage.

Does neoadjuvant doxorubicin drug-eluting bead transarterial chemoembolization improve survival in patients undergoing liver transplant for hepatocellular carcinoma?

PURPOSE: We aimed to compare the overall (OS) and disease-free survival (DFS) of patients undergoing orthotopic liver transplant (OLT) for hepatocellular carcinoma who did and did not have neoadjuvant doxorubicin drug-eluting bead transarterial chemoembolization (DEB-TACE). METHODS: This is a retrospective study of 94 patients with HCC transplanted between 2000 and 2014 in a single tertiary center. Pre- and postoperative features, DFS and OS were compared between patients who received pre-OLT DEB-TACE (n=34, DEB-TACE group) and those who did not (n=60, non-TACE group). Radiologic and histologic response to neoadjuvant treatment as well as its complications were also studied. RESULTS: There were no significant differences in post-transplantation DFS and OS rates between groups (5-year DFS: 70% in DEB-TACE group vs. 63% in non-TACE group, P = 0.454; 5-year OS: 70% in DEB-TACE group vs. 65% in non-TACE group, P = 0.532). The DEB-TACE group had longer OLT waiting time compared with the non-TACE group (110 vs. 72 days; P = 0.01). On univariate and multivariate analyses, alpha-fetoprotein (AFP) levels >500 ng/mL prior to OLT were associated with decreased OS and DFS regardless of neoadjuvant approach (hazard ratio of 6, P = 0.001 and 5.5, P = 0.002, respectively). CONCLUSION: Patients who underwent neoadjuvant DEB-TACE and OLT for hepatocellular carcinoma had no statistically different OS or DFS at 3 and 5 years from patients undergoing OLT alone.

A prospective study investigating the cost effectiveness of intraoperative blood salvage during liver transplantation.

BACKGROUND: Adult orthotopic liver transplantation is associated with significant use of allogenic blood products, which places considerable demands on finite resources. This could be reduced by autologous red cell salvage use, and we evaluated its cost effectiveness in this prospective study. METHODS: Intraoperative autotransfusion was used in 660 adult liver transplant patients between January 1997 and July 2002. These included 134 with acute liver failure, 62 retransplants, 90 alcohol-related, 183 viral, 98 cholestatic chronic liver diseases, and 93 with other etiologies. RESULTS: The total volume of red blood cells transfused was 3641+/-315 ml, 2805+/-234 ml, 2603+/-443 ml, and 2785+/-337 ml for alcohol-related, viral, cholestatic, and others, respectively. Low preoperative hemoglobin was significantly associated with higher intraoperative transfusion requirements. Blood volumes transfused at retransplantation were significantly higher (7077+/-1110 ml vs. 2864+/-138 ml; P<0.001) than for acute liver failure and chronic liver disease. Autologous blood volumes transfused were similar in all diagnostic groups, but were significantly greater in retransplantation (2754+/-541 ml vs. 1524+/-77 ml; P<0.01). Venovenous bypass was significantly associated with higher transfusion requirements. Total savings per case were similar for all diagnostic groups but were greater in cases of retransplantation (864+/-222 pounds (1235+/-317 US dollars) vs. 238+/-24 pounds (340+/-34 US dollars; P<0.001). With the use of autologous transfusion over the study period, a cost saving of 131,901 pounds (188,618 US dollars) was achieved. CONCLUSIONS: Intraoperative red blood cell salvage and autologous transfusion is cost effective in adult liver transplantation. Currently, where optimum resource utilization and fiscal constraint are paramount in healthcare delivery, autologous transfusion is an important adjunct in liver transplantation.

Liver transplantation for hepatocellular carcinoma in Ireland: Pre-operative alpha-fetoprotein predicts tumour recurrence in a 14-year single-centre national experience.

AIM: To examine the results of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) in Ireland over a 14-year period. METHODS: Cases of HCC receiving OLT between January 1995 and September 2009 in the Irish Liver Transplant Unit were reviewed from a prospectively maintained database. Outcome measures included overall and recurrence free survival, alpha-fetoprotein (AFP) and tumour pathological features. RESULTS: On explant pathology, 57 patients had HCC. The median follow-up time was 42.7 mo. The overall 1, 3 and 5 years survival was 87.7%, 72.1% and 72.4%. There was no difference in survival when compared to patients undergoing OLT without malignancy. The tumour recurrence rate was 14%. The Milan criteria were exceeded in 32% of cases but this did not predict overall survival or recurrence. On multivariate analysis pre-operative AFP > 100 ng/mL was an independent risk factor for recurrence (RR = 5.2, CI: 1.1-24.3, P = 0.036). CONCLUSION: Patients undergoing OLT for HCC had excellent survival even when conventional listing criteria were exceeded. Pre-operative AFP predicts recurrence independent of tumour size and its role in selection criteria should be investigated in larger studies.