Impact of tumor size on the outcomes of hepatic resection for hepatocellular carcinoma: a retrospective study.

BACKGROUND: To evaluate the impact of tumor size on the perioperative and long-term outcomes of liver resection for hepatocellular carcinoma (HCC). METHODS: We reviewed the patients' data who underwent liver resection for HCC between November 2009 and 2019. Patients were divided into 3 groups according to the tumor size. Group I: HCC < 5 cm, Group II: HCC between 5 to 10 cm, and Group III: HCC ≥ 10 cm in size. RESULTS: Three hundred fifteen patients were included in the current study. Lower platelets count was noted Groups I and II. Higher serum alpha-feto protein was noted in Group III. Higher incidence of multiple tumors, macroscopic portal vein invasion, nearby organ invasion and presence of porta-hepatis lymph nodes were found in Group III. More major liver resections were performed in Group III. Longer operation time, more blood loss and more transfusion requirements were found in Group III. Longer hospital stay and more postoperative morbidities were noted in Group III, especially posthepatectomy liver failure, and respiratory complications. The median follow-up duration was 17 months (7-110 months). Mortality occurred in 100 patients (31.7%) and recurrence occurred in 147 patients (46.7%). There were no significant differences between the groups regarding recurrence free survival (Log Rank, p = 0.089) but not for overall survival (Log Rank, p = 0.001). CONCLUSION: HCC size is not a contraindication for liver resection. With proper selection, safe techniques and standardized care, adequate outcomes could be achieved.

Feasibility and outcomes of living-donor liver transplantation utilizing the right hemi-liver graft with portal vein anatomical variations.

PURPOSE: Portal vein (PV) reconstruction is a key factor for successful living-donor liver transplantation (LDLT). Anatomical variations of right PV (RPV) are encountered among potential donors. METHODS: To evaluate a single center experience of reconstruction techniques for the right hemi-liver grafts with PV variations during the period between May 2004 and 2022. RESULTS: A total of 915 recipients underwent LDLT, among them 52 (5.8%) had RPV anatomical variations. Type II PV was found in 7 cases (13.5%), which were reconstructed by direct venoplasty. Type III PV was found in 27 cases (51.9%). They were reconstructed by direct venoplasty in 2 cases (3.8%), Y graft interposition in 2 cases (3.8%), and in situ double PV anastomoses in 23 cases (44.2%). Type IV PV was found in 18 cases (34.6%) and was reconstructed by Y graft interposition in 9 cases (17.3%), and in situ double PV anastomoses in 9 cases (17.3%). Early right posterior PV stenosis occurred in 2 recipients (3.8%). Early PV thrombosis occurred in 3 recipients (5.8%). The median follow-up duration was 54.5 months (4 - 185). The 1-, 3-, and 5-years survival rates were 91.9%, 86%, and 81.2%, respectively. Late PV stenosis occurred in 2 recipients (3.8%) and was managed conservatively. CONCLUSION: Utilization of potential living donors with RPV anatomic variations may help to expand the donor pool. We found that direct venoplasty and in situ dual PV anastomoses techniques were safe, feasible, and associated with successful outcomes.

Predictive factors of postendoscopic retrograde cholangiopancreatography pancreatitis for biliary complications in living-donor liver transplantation recipients.

OBJECTIVES: Endoscopic retrograde cholangiopancreatography (ERCP) has shown great safety and efficacy in the management of post-living-donor liver transplantation (LDLT) biliary complications. Pancreatitis is the most commonest and the most feared complication after ERCP. METHODS: We reviewed the data of liver transplant recipients who underwent ERCP for biliary complications after LDLT between 2011 and 2022. RESULTS: In total 63 patients underwent ERCP after LDLT. They were targeted to 134 set of ERCP. Pancreatitis occurred in 52 sets (38.8%). We subclassified the patients into two groups, without pancreatitis: 31 patients (49.2%) and with pancreatitis 32 patients (50.8%). A higher incidence of pancreatitis was noticed with the first ERCP set (P = 0.04). Biliary strictures were more noted in the pancreatitis group (P = 0.025). Difficult cannulation requiring precut was more observed in the pancreatitis group (P = 0.007). Also, more frequent sphincterotomy was observed in the pancreatitis group (P = 0.003). Longer hospital stay, more fever, abdominal pain and vomiting were noted in the pancreatitis group (P = 0.001). Higher post-ERCP serum amylase (P = 0.001) and creatinine (P = 0.021), while lower serum calcium (P = 0.21) were noticed in the pancreatitis group. On multivariate analysis, preoperative diabetes, number of biliary anastomoses (single/multiple) and difficult cannulation requiring precut were significant predictors of post-ERCP pancreatitis. CONCLUSION: Patient-related risk factors and bedside procedure-related risk factors play an essential role in the development of pancreatitis after ERCP for LDLT recipients. Endoscopists should be mindful by those high-risk patients during ERCP to apply appropriate techniques to prevent the development of this serious complication.

Short-term effects of extracorporeal graft rinse versus circulatory graft rinse in living donor liver transplantation. A prospective randomized controlled trial.

Living donor liver transplantation has shorter cold ischemia time, less preservative volume, and lower metabolic load compared to transplantation from deceased donors. We investigated the impact of rinsing the graft contents into the systemic circulation on operative course and postoperative outcomes. Donors had right hepatectomy, and grafts were preserved with cold histidine-tryptophan-ketoglutarate solution. On ending portal vein anastomosis, grafts were flushed by patient's portal blood either through incompletely anastomosed hepatic vein (extracorporeal rinse group, EcRg, n = 40) or into systemic circulation (circulatory rinse group, CRg, n = 40). The primary outcome objective was the lowest mean arterial blood pressure within 5 min after portal unclamping as a marker for postreperfusion syndrome (PRS). Secondary objectives included hemodynamics and early graft's and patient's outcomes. Within 5 min postreperfusion, mean arterial blood pressure was significantly lower in the CRg compared to the EcRg, yet this was clinically insignificant. Postoperative graft functions, early biliary and vascular complications, and three-month survival were comparable in both groups. Rinsing the graft into the circulation increased the incidence of PRS without significant impact on early graft or patient outcome in relatively healthy recipients.

Impact of donor-recipient genetic relationship on outcome of living donor liver transplantation.

Living donor liver transplantation (LDLT) is a valuable option for expanding the donor pool, especially in localities where deceased organ harvesting is not allowed. In addition, rejection rates were found to be lower in LDLT, which is attributed to the fact that LDLT is usually performed between relatives. However, the impact of genetic relation on the outcome of LDLT has not been studied. In this study, we examined the difference in rejection rates between LDLT from genetically related (GR) donors and genetically unrelated (GUR) donors. All cases that underwent LDLT during the period from May 2004 until May 2014 were included in the study. The study group was divided into 2 groups: LDLT from GR donors and LDLT from GUR donors. A total of 308 patients were included in the study: 212 from GR donors and 96 from GUR donors. Human leukocyte antigen (HLA) typing was not included in the workup for matching donors and recipients. GUR donors were wives (36; 11.7%), sons-in-law (7; 2.3%), brothers-in-law (12; 3.9%), sisters-in-law (1; 0.3%), and unrelated (38; 12.3%). The incidence of acute rejection in the GR group was 17.4% and 26.3% in the GUR group (P value = 0.07). However, there was a significant difference in the incidence of chronic rejection (CR) between the 2 groups: 7% in GR group and 14.7% in the GUR group (P value = 0.03). In terms of overall survival, there was no significant difference between both groups. LDLT from the GUR donors is not associated with a higher incidence of acute cellular rejection. However, CR was significantly lower when grafts were procured from GR donors. HLA matching may be recommended before LDLT from GUR donors. Liver Transplantation 23:43-49 2017 AASLD.

The impact of portopulmonary hypertension on intraoperative right ventricular function of living donor liver transplant recipients.

BACKGROUND: Portopulmonary hypertension (PPH) burdens a right ventricle (RV) already exposed to physiologic stress during liver transplantation. The magnitude of the impact of PPH on RV function, especially early reperfusion, has not been evaluated adequately by prospective controlled trials. In this study, we prospectively quantified the impact of PPH on the RV function in living donor liver transplant recipients. METHODS: Twenty patients undergoing living donor liver transplant were stratified based on mean pulmonary artery pressure (mPAP) into a control group (mPAP <25 mm Hg) and a PPH group (mPAP ≥25 mm Hg). Standard anesthetic technique and monitoring were used. Fiberoptic pulmonary artery catheters enabled to measure RV ejection fraction (RVEF) were used. Hemodynamics were recorded after induction of anesthesia, the end of hepatectomy, before portal unclamping, 5 and 30 minutes after reperfusion, and at skin closure. RESULTS: The PPH group had significantly lower RVEF, stroke volume, and higher central venous pressure and RV end-diastolic volume index after portal unclamping versus the controls. Pulmonary vascular resistance index and mPAP were significantly higher throughout the operation in the PPH group, but RV stroke work index did not differ significantly between groups. RVEF was significantly reduced in the PPH group after reperfusion compared with baseline, but the control group did not experience such a reduction. CONCLUSIONS: Mild to moderate PPH was associated with reduced RVEF during liver transplantation, especially after reperfusion, likely because of a reduced RV contractile reserve in PPH patients. This reduction in RVEF was clinically well tolerated by patients with mild to moderate PPH.