Transferability of Liver Transplantation Experience to Complex Liver Resection for Locally Advanced Hepatobiliary Malignancy-Lessons Learnt From 3 Decades of Single Center Experience.

OBJECTIVE: To study the impact of LT experience on the outcome of CLR for locally advanced hepatobiliary malignancy. SUMMARY OF BACKGROUND DATA: Despite evolution in LT knowledge and surgical techniques in the past decades, there is yet data to evaluate the significance of LT experience in performing CLR. METHODS: Postoperative outcome after CLR between 1995 and 2019 were reviewed and correlated with LT experience in a single center with both LT and CLR service. CLR was defined as hepatectomy with vasculobiliary reconstruction, or multivisceral resection, central bisectionectomy (S4/5/8), or associating liver partition and portal vein ligation for staged hepatectomy. Spearman rank correlation and receiver operating characteristic analysis were used to define the association between CLR-related outcomes and LT experience. RESULTS: With cumulative single-center experience of 1452 LT, 222 CLR were performed during the study period [hepatectomy with biliary (27.0%), or vascular (21.2%) reconstruction, with multivisceral resections (9.9%), with associating liver partition and portal vein ligation for staged hepatectomy (18.5%)] mainly for hepatocellular carcinoma (53.2%), and hilar cholangiocarcinoma (14%). Median tumor size was 7.0 cm. Other features include macrovascular invasion (23.4%), and juxta-visceral invasion (14%). Major postoperative complication rate was 25.2% and mortality rate was 6.3%. CLR-complication rate was inversely associated with LT experience (R = -0.88, P < 0.005). Receiver operator characteristic analysis revealed the cutoff for LT experience to have the greatest influence on CLR was 95 with a sensitivity of 100% and Youden index of 1. Multivariable analysis showed that blood transfusion, prolonged operating time, LT experience < /=95 were associated with major postoperative complications. CONCLUSION: LT experience was complimentary to CLR for locally advanced hepatobiliary malignancy with improved postoperative outcome.

Critical appraisal of TNM versus HKU staging system for postoperative prognostic evaluation of hepatocellular carcinoma.

BACKGROUND: The 8th edition of the American Joint Committee on Cancer tumor-node-metastasis staging system (AJCC 8th) has been launched with modifications in T staging. The University of Hong Kong liver cancer staging system (HKUSS) has been proven to better categorize hepatocellular carcinoma (HCC) into different T stages. This study aimed to compare the two systems' predictive ability for HCC recurrence after primary surgical resection. METHODS: Patients who had primary, curative resection for HCC between 1989 and 2017 were reviewed. The Kaplan-Meier plot was used to estimate disease-free survival (DFS), and the log-rank test was used for survival comparison between subgroups. The two systems' prediction of recurrence was evaluated by the Cox regression model. RESULTS: Totally 1,815 patients were included. With AJCC 8th, the 5-year DFS was 58.9% for T1a, 52.3% for T1b, 30% for T2, 16.9% for T3, and 14.4% for T4. No survival difference was demonstrated between T1a and T1b (P=0.668) or between T3 and T4 (P=0.562). With HKUSS, the 5-year DFS was 57.7% for T1, 43.4% for T2, 28.9% for T3, and 15.7% for T4. The T staging in HKUSS showed significant survival differences (T1 vs. T2, T2 vs. T3, and T3 vs. T4; P<0.001). Using receiver operating characteristic curves to show the recurrence status in the two systems, HKUSS had the largest area under curve (AUC) (HKUSS: AUC =0.655, SE 0.014, P<0.001, 95% CI, 0.628-0.681; AJCC 8th: AUC =0.652, SE 0.013, P<0.001, 95% CI, 0.625-0.677). CONCLUSIONS: HKUSS showed better categorization of HCC. In the context of primary surgical resection, HKUSS may be more appropriate for stratification of patients with HCC with various T stages, and thus the choice of staging system when primary surgical resection is considered for patients of HCC.

Role of C11-FDG dual-tracer PET-CT scan in metastatic screening of hepatocellular carcinoma-a cost-effectiveness analysis.

BACKGROUND: We aimed to identify predictive factors for positron emission tomography (PET)-detected hepatocellular carcinoma (HCC) metastasis and a cost-effective approach to preoperative PET-computed tomography (CT) for detecting metastasis. METHODS: Clinicopathological and survival data of HCC patients having PET-CT with 18F-fludeoxyglucose (FDG) and 11C-acetate (ACT) following contrast-enhanced CT/magnetic resonance imaging (MRI) for preoperative tumor staging were reviewed. Binary logistic regression was performed to identify predictive factors for PET-detected metastasis. A cost-benefit analysis model was built for the incurred costs and the impact of PET-CT findings on treatment strategy was studied. RESULTS: Totally 152 patients were analyzed. Dual-tracer PET-CT detected metastasis in 17 patients (11%). By multivariate analysis, alpha-fetoprotein (AFP) ≥400 ng/mL [relative risk (RR): 4.30, 95% confidence interval (CI): 1.41-13.15, P=0.011] and bilobar disease (RR: 3.94, 95% CI: 1.24-12.52, P=0.014) were independent predictive factors for PET-detected metastasis. PET-CT findings altered the treatment strategy for 12 patients (7.9%); three partial hepatectomies, eight episodes of transarterial chemoembolization (TACE) and one episode of ablation were avoided, with an estimated cost-saving of US $91,000, $150,000 and $10,600 respectively. Had the PET-CT been performed only for patients with AFP ≥400 ng/mL or bilobar disease (n=74), metastasis would have been confirmed in 14 patients (18.9%), and the cost-saving per patient was estimated at US $1,070. CONCLUSIONS: Dual-tracer PET-CT is cost-effective and useful for preoperative HCC staging in patients with AFP ≥400 ng/mL or bilobar disease. Its routine use in preoperative workup for all HCC patients is not recommended. Unilobar disease with AFP <400 ng/mL can achieve good negative predictive value for PET-detected metastasis. Screening patients with either factor can avoid unnecessary procedures and is thus cost-effective for preoperative HCC workup.

The Risk of Going Small: Lowering GRWR and Overcoming Small-For-Size Syndrome in Adult Living Donor Liver Transplantation.

OBJECTIVE: The aim of this study was to determine the outcomes of living donor liver transplantation (LDLT) according to various graft-to-recipient weight ratio (GRWR). BACKGROUND: The standard GRWR in LDLT is >0.8%. Our center accepted predicted GRWR ≥0.6% in selected patients. METHODS: Data from patients who underwent LDLT from 2001 to 2017 were included. Patients were stratified according to actual GRWR (Group 1:GRWR ≤0.6%; Group 2: 0.6%0.8%). RESULTS: There were 545 LDLT (group 1 = 39; group 2 = 159; group 3 = 347) performed. Pretransplant predicted GRWR showed good correlation to actual GRWR (R2 = 0.834) and these figures differed within a ±â€Š10%margin (P = 0.034) using an equivalence test. There were more left lobe grafts in group 1 (33.3%) than group 2 (10.7%) and 3 (2.9%). Median donor age was <35 years and steatosis >10% was rare.There was no difference in postoperative complication, vascular and biliary complication rate between groups. Over one-fifth (20.5%) of group 1 patients required portal flow modulation (PFM) and was higher than group 2 (3.1%) and group 3 (4%) (P = 0.001). Twenty-six patients developed small-for-size syndrome (SFSS): 5 of 39 (12.8%) in group 1 and 21 of 159 (13.2%) in group 2 and none in group 3 (P < 0.001). There were 2 hospital mortalities; otherwise, the remaining patients [24/26 (92.3%)] survive with a functional liver graft. The 5-year graft survival rates were 85.4% versus 87.8% versus 84.7% for group 1, 2, and 3, respectively (P = 0.718). GRWR did not predict worse survivals in multivariable analysis. CONCLUSIONS: Graft size in LDLT can be lowered to 0.6% after careful recipient selection, with low incidence of SFSS and excellent outcomes. Accurate graft weight prediction, donor-recipient matching, meticulous surgical techniques, appropriate use of PFM, and vigilant perioperative care is important to the success of such approach.

Determining the optimal timing of liver transplant for pediatric patients after Kasai portoenterostomy based on disease severity scores.

BACKGROUND: The objective of this study was to determine the most optimal timing of liver transplant (LT) for post-Kasai portoenterostomy (KPE) patients based on disease severity scores. METHODS: This was a retrospective study and the clinical data of all LT recipients aged <18 years (n = 89) with a history of KPE were analyzed. They were divided into three groups according to their PELD/MELD scores at the time of LT (A: <15; B: 15-25; C: >25). The effects of LT on the clinical outcomes and hospitalization status were analyzed. RESULTS: There were 33, 34 and 22 patients in group A, B and C, respectively. There was no significant difference in 3-year graft survival rate between the three groups but group C patients had the highest incidence of vascular or biliary complications (p = 0.022). Group C patients had a significantly lower hospital admission frequency (p = 0.036) and shorter hospital stay (p = 0.041) after LT when compared with their pre-LT status and with non-LT patients with similar disease severity scores. On the other hand, the hospitalization frequency and duration were similar in patients with the lowest disease severity score (group A) before, after and without LT. CONCLUSIONS: The benefit of LT was less obvious when the disease severity score is <15. A high complication rate was reported when LT was performed at a score > 25. Donor availability, the patient's general condition and parental wish should be considered during individual assessment. TYPE OF STUDY: Clinical research paper. LEVEL OF EVIDENCE: Level III.

Long-Term Survival Outcome Between Living Donor and Deceased Donor Liver Transplant for Hepatocellular Carcinoma: Intention-to-Treat and Propensity Score Matching Analyses.

BACKGROUND: Previous studies comparing outcomes of hepatocellular carcinoma (HCC) patients after living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT) showed conflicting results, and most studies measured survival outcomes from the time of liver transplantation (LT). METHOD: This retrospective study was aimed to evaluate the long-term outcomes of HCC patients listed for LT using intention-to-treat (ITT) and propensity score matching (PSM) analyses. Clinicopathological data were retrieved from a prospectively collected database. RESULTS: From 1995 to 2014, 375 HCC patients were listed for LT. ITT-LDLT group had 188 patients, whereas ITT-DDLT group had 187 patients. Twenty-seven patients (14.4%) and 122 patients (65.2%) were delisted from LDLT and DDLT waitlist, respectively. The 1-, 3- and 5-year overall survival rates were significantly better in ITT-LDLT group than ITT-DDLT group (94.1 vs. 77.5%, 81.4 vs. 48.7% and 75.9 vs. 40.8%). High alphafetoprotein (AFP) and ITT-DDLT treatment arm were independent poor prognostic factors affecting overall survival. LDLT group (n = 161) had more young patients, poorer liver function, higher AFP, more tumors outside Milan/UCSF criteria, when compared with DDLT group (n = 85). After PSM, the 1-, 3- and 5-year overall (95.4 vs. 98.5%, 80.0 vs. 92.3% and 73.4 vs. 84.4%) and recurrence-free (87.7% vs. 90.8%, 76.9% vs. 83.1% and 72.2% vs. 81.5%) survival rates were comparable between the matched LDLT and the matched DDLT group, respectively. CONCLUSION: Survival benefit of LDLT was observed for HCC patients with ITT analysis. Despite a more advanced tumor stage, overall and recurrence-free survival rates were comparable between LDLT and DDLT using PSM analysis.

Pneumocystis jirovecii-related spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema in a liver transplant recipient: a case report.

BACKGROUND: Pneumocystis pneumonia (PCP) is a common opportunistic infection caused by Pneumocystis jirovecii. Its incidence at 2 years or more after liver transplant (LT) is < 0.1%. PCP-related spontaneous pneumothorax and/or pneumomediastinum is rare in patients without the human immunodeficiency virus, with an incidence of 0.4-4%. CASE PRESENTATION: A 65-year-old woman who had split-graft deceased-donor LT for primary biliary cirrhosis developed fever, dyspnea and dry coughing at 25 months after transplant. Her immunosuppressants included tacrolimus, mycophenolate mofetil, and prednisolone. PCP infection was confirmed by molecular detection of Pneumocystis jirovecii,in bronchoalveolar lavage. On day-10 trimethoprim-sulphamethoxazole, her chest X-ray showed subcutaneous emphysema bilaterally, right pneumothorax and pneumomediastinum. Computed tomography of the thorax confirmed the presence of right pneumothorax, pneumomediastinum and subcutaneous emphysema. She was managed with 7-day right-sided chest drain and a 21-day course of trimethoprim-sulphamethoxazole before discharge. CONCLUSION: Longer period of PCP prophylaxis should be considered in patients who have a higher risk compared to general LT patients. High index of clinical suspicion, prompt diagnosis and treatment with ongoing patient reassessment to detect and exclude rare, potentially fatal but treatable complications are essential, especially when clinical deterioration has developed.

Anterior Approach to Major Resection for Colorectal Liver Metastasis.

PURPOSE: The aim of this study was to examine the merits of the anterior approach, if any, in colorectal liver metastasis (CRLM) resection. METHODS: Data of patients who underwent partial hepatectomy for CRLM were reviewed. Patients treated by the anterior approach were compared with patients treated by the conventional approach. RESULTS: Ninety-eight patients had right hepatectomy, extended right hepatectomy, or right trisectionectomy. Among them, 71 patients underwent the conventional approach (CA group) and 27 underwent the anterior approach (AA group). The two groups were comparable in demographic, pathological, and perioperative characteristics except that the AA group had higher levels of aspartate transaminase (median, 41 vs. 31 U/L; p = 0.006) and alanine transaminase (median, 27 vs. 22 U/L; p = 0.009), larger tumors (median, 7 vs. 4 cm; p = 0.000), and more extensive resections (p < 0.001). The median overall survival was 40 months (range, 0.69-168.6 months) in the CA group and 33.7 months (range, 0.95-99.8 months) in the AA group (p = 0.22), and the median disease-free survival was 9.7 months (range, 0.62-168.6 months) in the CA group and 6.2 months (range, 0.72-99.8 months) in the AA group (p = 0.464). Univariate and multivariate analyses identified 4 independent prognostic factors for overall survival: lymph node status of primary tumor (HR 1.352, 95% CI 0.639-2.862, p = 0.034), intraoperative blood loss (HR 1.253, 95% CI 1.039-1.510, p = 0.018), multiple liver tumor nodules (HR 1.775, 95% CI 1.029-3.061, p = 0.039), and microvascular invasion (HR 2.058, 95% CI 1.053-4.024, p = 0.035). CONCLUSIONS: The two approaches resulted in comparable survival outcomes even though the AA group had larger tumors and more extensive resections. The anterior approach allows better mobilization and easier removal of large tumors once the liver is opened up.

Recurrent pyogenic cholangitis - an independent poor prognostic indicator for resectable intrahepatic cholangiocarcinoma: A propensity score matched analysis.

BACKGROUND: Recurrent pyogenic cholangitis (RPC) is a known risk factor for intrahepatic cholangiocarcinoma (ICC), whether it represents a poor prognostic factor remains controversial. The aim of this study was to investigate the post-hepatectomy oncological outcomes of patients with ICC and coexisting RPC. METHOD: A retrospective analysis with propensity score matching (PSM) was performed for comparison between ICC patient with and without RPC. RESULTS: There were 143 patients with ICC with a median follow-up of 21 months. RPC was diagnosed in 18% of patients. The time from RPC diagnosis to ICC diagnosis was 137(47-481) months. The 3-year disease-free (DFS) and overall survival for the whole population was 34% and 43% respectively. Preoperative child score, elevated carcinoembryonic antigen, presence of microvascular invasion, multiple tumours, presence of postoperative complications and RPC were independent factors for DFS and OS. After PSM, 60 ICC patients who did not have RPC were compared with 20 ICC patients with RPC. Patients with RPC had significantly worse median DFS (10 vs 23 months, P = 0.020) and OS (15 vs 45 months, P = 0.004) when compared to the patients without RPC. CONCLUSION: RPC represents a poor prognostic factor affecting outcomes after hepatectomy for patients with ICC.

Impact of intraoperative blood transfusion on long-term outcomes of liver transplantation for hepatocellular carcinoma.

OBJECTIVE: To investigate the impact of intraoperative blood transfusion on the long-term outcomes of liver transplantation for hepatocellular carcinoma. METHOD: Adult patients who had non-salvage liver transplantation at our centre between January 2005 and December 2012 for hepatocellular carcinomas that were within the University of California, San Francisco criteria and could not be resected or ablated were divided into groups with and without intraoperative blood transfusion. Comparisons were made between groups. RESULTS: Ninety-nine patients were included in the study. Sixty-two (62.6%) patients received intraoperative blood transfusion. Patients without transfusion were younger (54 versus 56 years; P = 0.04) and had a lower Model for End-stage Liver Disease score (11 versus 14; P < 0.001). Most of them had stage-I tumours (64.9 versus 37.1%; P = 0.007) and fewer of them had postoperative complications of grade IIIA or above in the Clavien-Dindo classification (21.6 versus 48.4%; P = 0.008). The groups were comparable in hospital mortality (3.2 versus 2.7%; P = 1.00), 5-year overall survival (90.8 versus 89.2%; P = 0.611) and 5-year disease-free survival (90.5 versus 89.2%; P = 0.835). On multivariate analysis, postoperative complications of grade IIIA or above were associated with worse survival (hazard ratio, 7.108; 95% confidence interval, 1.455-34.712; P = 0.015). CONCLUSION: Intraoperative blood transfusion was shown to have no significant impact on the long-term outcomes of liver transplantation for hepatocellular carcinoma, whereas postoperative complications of grade IIIA or above were associated with worse recipient survival.

Risk prediction model for major complication after hepatectomy for malignant tumour - A validated scoring system from a university center.

OBJECTIVE: To derive and validate a scoring system for major complication after hepatectomy. BACKGROUND: Complications after hepatectomy significantly compromise survival outcomes, method to predict such risk is lacking. A reliable scoring system is therefore awaited. METHODS: Consecutive adult patients receiving hepatectomy for primary or secondary liver malignancy from 1995 to 2014 were recruited. After randomization, patients were allocated to derivation and validation group respectively. A scoring system predicting occurrence of major complication was developed. RESULTS: There were 2613 patients eligible for the study. The overall complication rate for the series was 10%. Impaired performance status (p = 0.014), presence of pre-existing medical illness (p = 0.008), elevated ALP (p = 0.005), urea (p < 0.001), and hypoalbuminemia (p = 0.008), and major hepatectomy (p < 0.001) were found to be independently associated major complications. A score was assigned to each of these factors according to their respective odd ratio. A total score of 0-17 was calculated for all patients. This score was shown to discriminate well with complication rate in both derivation and validation group (c-statistic: 0.71, p < 0.001 and 0.74, p < 0.001 respectively). The complication rate for low (score 0-5), moderate (score 6-10) and high (score 10 or above) risk group were respectively 5%, 16% and 28%. This risk stratification model was tested and confirmed in the validation group using Chi-square goodness-of-fit test (p = 0.864). CONCLUSION: A validated risk stratification model provides an accurate and easy-to-use reference tool for patients and clinicians during the informed consent process.

A new formula for estimation of standard liver volume using computed tomography-measured body thickness.

The objective of this article is to derive a more accurate and easy-to-use formula for finding estimated standard liver volume (ESLV) using novel computed tomography (CT) measurement parameters. New formulas for ESLV have been emerging that aim to improve the accuracy of estimation. However, many of these formulas contain body surface area measurements and logarithms in the equations that lead to a more complicated calculation. In addition, substantial errors in ESLV using these old formulas have been shown. An improved version of the formula for ESLV is needed. This is a retrospective cohort of consecutive living donor liver transplantations from 2005 to 2016. Donors were randomly assigned to either the formula derivation or validation groups. Total liver volume (TLV) measured by CT was used as the reference for a linear regression analysis against various patient factors. The derived formula was compared with the existing formulas. There were 722 patients (197 from the derivation group, 164 from the validation group, and 361 from the recipient group) involved in the study. The donor's body weight (odds ratio [OR], 10.42; 95% confidence interval [CI], 7.25-13.60; P < 0.01) and body thickness (OR, 2.00; 95% CI, 0.36-3.65; P = 0.02) were found to be independent factors for the TLV calculation. A formula for TLV (cm3 ) was derived: 2 × thickness (mm) + 10 × weight (kg) + 190 with R2 0.48, which was the highest when compared with the 4 other most often cited formulas. This formula remained superior to other published formulas in the validation set analysis (R2 , 5.37; interclass correlation coefficient, 0.74). Graft weight/ESLV values calculated by the new formula were shown to have the highest correlation with delayed graft function (C-statistic, 0.79; 95% CI, 0.69-0.90; P < 0.01). The new formula (2 × thickness + 10 × weight + 190) represents the first study proposing the use of CT-measured body thickness which is novel, easy to use, and the most accurate for ESLV. Liver Transplantation 23 1113-1122 2017 AASLD.

Survival outcomes of hepatocellular carcinoma resection with postoperative complications - a propensity-score-matched analysis.

Curative resection remains the only hope of cure for hepatocellular carcinoma (HCC), but postoperative complications can have a significant impact on long-term survival. However, only scarce data on such impact can be found in the literature.This retrospective study reviewed the prospectively collected data of patients who underwent primary liver resection for HCC at our hospital during the period from December 1989 to December 2014. Patients with and without postoperative complications were compared. A 1:1 propensity score matching was adopted by matching age, comorbidity, Model of End-stage Liver Disease score, tumor stage, and extent of resection.Totally 1710 patients were eligible for the study. Four hundred and sixty-one (27.0%) of them developed postoperative complications while 1249 (73.0%) did not. After propensity score matching, 922 patients were compared in a 1:1 ratio (461 with postoperative complications and 461 without). Patients who developed postoperative complications were demographically similar to patients who did not, but had more intraoperative blood loss and transfusion (both P < 0.001), longer hospital stay (17 vs 9 days; P < 0.001), worse hospital mortality (12.1% vs 0%; P < 0.001), and shorter overall survival (P < 0.001). On multivariate analysis, factors that might have affected overall survival were cancer stage (HR 1.22, P < 0.001), tumor size (HR 1.02, P = 0.005), tumor number (HR 1.08, P < 0.001), venous invasion (HR 1.38, P = 0.003), extent of resection (HR 1.19, P = 0.045), intraoperative blood loss (HR 1.11, P < 0.001), postoperative complication (HR 1.37, P < 0.001), and era effect (HR 1.27, P = 0.01).Patients should be monitored closely after HCC resection. Prompt treatment of postoperative complications may be salvational.

Lipid profiles of donors and recipients of liver transplant: like father like son.

BACKGROUND/PURPOSE: Dyslipidemia is common in liver transplant recipients. This retrospective study investigates whether donors play a role. METHODS: Prospectively collected data of donors and recipients of deceased-donor liver transplantation (DDLT) and living-donor liver transplantation (LDLT) were reviewed. Total cholesterol, triglyceride, low-density lipoprotein, high-density lipoprotein (HDL) and fasting glucose were compared between groups. HDL ≥1.6 mmol/L at 2 years after transplant was considered the marker of a favorable post-transplant lipid profile in recipients. Univariate and multivariate analyses were performed to identify predictive factors for this marker. RESULTS: There were 85 DDLTs and 80 LDLTs. LDLT donors were younger (30 vs. 50 years, p < 0.001) and lighter (58.2 vs. 63.4 kg, p = 0.008) and had a lower body mass index (21.2 vs. 23.7, p < 0.001). The DDLT group had more fatty grafts (p = 0.001) and longer cold (375 vs. 103.5 min, p < 0.001) and warm (50.5 vs. 46 min, p = 0.034) ischemia. LDLT donors had lower fasting glucose (4.85 vs. 7.21 mmol/L, p < 0.001) and triglyceride (0.87 vs. 1.22 mmol/L, p = 0.016) but higher HDL (1.58 vs. 1.39 mmol/L, p = 0.022). LDLT recipients also had higher HDL at 1 year (1.48 vs. 1.28 mmol/L, p = 0.026) and 2 years (1.43 vs. 1.21 mmol/L, p = 0.008). Fourteen (16.5%) DDLT recipients and 27 (33.8%) LDLT recipients had HDL ≥1.6 mmol/L at 2 years. On multivariate analysis, donor HDL ≥1.6 mmol/L (RR 4.311, 95% CI 1.666-11.158, p = 0.003) and recipient body mass index <24 (RR 2.753, 95% CI 1.064-7.127, p = 0.037) were the two independent predictive factors. CONCLUSION: LDLT recipients had better lipid profiles than DDLT recipients. The feature of high HDL level in donors was transferred to recipients.

Comparable Short- and Long-term Outcomes in Living Donor and Deceased Donor Liver Transplantations for Patients With Model for End-stage Liver Disease Scores ≥35 in a Hepatitis-B Endemic Area.

OBJECTIVE: To evaluate if living donor liver transplantation (LDLT) should be offered to patients with Model for End-stage Liver Disease (MELD) scores ≥35. BACKGROUND: No data was available to support LDLT of such patients. METHODS: Data of 672 consecutive adult liver transplant recipients from 2005 to 2014 at our center were reviewed. Patients with MELD scores ≥35 were divided into the deceased donor liver transplantation (DDLT) group and the LDLT group and were compared. Univariate analysis was performed to identify risk factors affecting survival. RESULTS: The LDLT group (n = 54) had younger (33 yrs vs 50 yrs, P < 0.001) and lighter (56 Kg vs 65 Kg, P = 0.004) donors, lighter grafts (627.5 g vs 1252.5 g, P < 0.001), lower graft-weight-to-recipient-standard-liver-volume rates (51.28% vs 99.76%, P < 0.001), shorter cold ischemic time (106.5 min vs 389 min, P < 0.001), and longer operation time (681.5 min vs 534 min, P < 0.001). The groups were comparable in postoperative complication, hospital mortality, and graft survival and patient survival at one year (88.9% vs 92.5%; 88.9% vs 94.7%), three years (87.0% vs 86.9%; 87.0% vs 88.8%), and five years (84.8% vs 81.8%; 84.8% vs 83.3%). Univariate analysis did not show inferior survival in LDLT recipients. CONCLUSIONS: At centers with experience, the outcomes of LDLT can be comparable with those of DDLT even in patients with MELD scores ≥35. When donor risks and recipient benefits are fully considered and balanced, an MELD score ≥35 should not be a contraindication to LDLT. In Hong Kong, where most waitlisted patients have acute-on-chronic liver failure from hepatitis B, LDLT is a wise alternative to DDLT.

Systematic review and meta-analysis of studies of biliary reconstruction in adult living donor liver transplantation.

BACKGROUND: The chance of biliary complication after living donor liver transplantation (LDLT) is considerable. The objective of this study was to investigate the impact of biliary reconstruction method on post-LDLT biliary complications. Data sources are from PubMed and Web of Science. METHODS: A systematic search was conducted using the search term '[biliary complications] OR [biliary complication] OR [biliary stricture] OR [bile leak] AND [living donor liver transplantation]'. Cross-referencing was allowed so as to encompass more potentially relevant studies. All English papers on adult LDLT published between 1990 and 2014 were considered for review. Papers focusing on biliary reconstruction method in relation to post-LDLT biliary complications were included. RESULTS: The meta-analysis recruited six retrospective studies but no randomized trial or prospective study. The six studies covered 1286 patients with 260 cases (20.2%) of biliary anastomotic stricture (BAS) and 118 cases (9.2%) of biliary leakage (BL). For biliary reconstruction, 365 patients (28.4%) underwent hepaticojejunostomy (HJ) and 909 (70.7%) underwent duct-to-duct anastomosis (DDA), while 12 (0.9%) underwent both and were thus excluded from the analysis. A lower rate of BAS was found in patients with HJ compared with patients with DDA (Mantel-Haenszel odds ratio 0.448, 95% confidence interval 0.311-0.643; P = 0.000). Rates of BL were similar in the two groups (Mantel-Haenszel odds ratio 1.27, 95% confidence interval 0.821-1.966; P = 0.283). CONCLUSION: In the comparison of HJ and DDA in adult LDLT, the latter was found to be associated with a bigger chance of BAS but not BL.

Management of hepatocellular carcinoma with portal vein tumor thrombosis: Review and update at 2016.

Portal vein tumor thrombosis (PVTT) is a common phenomenon in hepatocellular carcinoma (HCC). Compared to HCC without PVTT, HCC with PVTT is characterized by an aggressive disease course, worse hepatic function, a higher chance of complications related to portal hypertension and poorer tolerance to treatment. Conventionally, HCC with PVTT is grouped together with metastatic HCC during the planning of its management, and most patients are offered palliative treatment with sorafenib or other systemic agents. As a result, most data on the management of HCC with PVTT comes from subgroup analyses or retrospective series. In the past few years, there have been several updates on management of HCC with PVTT. First, it is evident that HCC with PVTT consists of heterogeneous subgroups with different prognoses. Different classifications have been proposed to stage the degree of portal vein invasion/thrombosis, suggesting that different treatment modalities may be individualized to patients with different risks. Second, more studies indicate that more aggressive treatment, including surgical resection or locoregional treatment, may benefit select HCC patients with PVTT. In this review, we aim to discuss the recent conceptual changes and summarize the data on the management of HCC with PVTT.

Short- and long-term impact of reoperation for complications after major hepatectomy for hepatocellular carcinoma.

BACKGROUND: The impact of reoperation for complications after major liver resection for hepatocellular carcinoma was evaluated. METHODS: In this retrospective study covering 25 years, patients with reoperation for complications after major liver resection for hepatocellular carcinoma were compared with patients without reoperation in terms of demographics, tumor characteristics, operative details, postoperative results, oncologic outcomes, and survival. Reasons for reoperation were also investigated. RESULTS: Forty-nine out of 1,092 patients underwent reoperation within a median of 0.2 days (range, 0-6.9 days) after hepatectomy. Patients with and without reoperation had similar baseline characteristics and liver function. Nonetheless, patients with reoperation had a higher indocyanine green retention rate at 15 minutes (12.55% vs 10.5%, P = .015), more operative blood loss (1.4 L vs 1 L, P = .012), a higher blood transfusion rate (44.9% vs 29.2%, P = .029), longer hospital stay (21 days vs 11 days, P < .001), a higher hospital mortality (38.8% vs 3.0%, P < .001), and a higher 90-day mortality (38.8% vs 4.7%, P < .001). Hemorrhage was the most common cause for reoperation (26/49, 53.1%), mainly resulting from coagulopathic bleeding from raw areas (12/26, 46.2%) and bleeding from diaphragmatic veins (6/26, 23.1%). However, reoperation did not affect 5-year overall survival (50.2% vs 48.3%, P = .468). CONCLUSION: Postoperative hemorrhage was associated with a high mortality, signifying the importance of meticulous hemostasis and careful perioperative management. Oncologic outcomes, however, were not affected by reoperation.

The effect of wide resection margin in patients with intrahepatic cholangiocarcinoma: A single-center experience.

INTRODUCTION: Prognosis of intrahepatic cholangiocarcinoma (ICC) remained poor despite the multitude advancement of medical care. Resection margin status is one of the few modifiable factors that a surgeon could possibly manipulate to alter the disease outcome. However, the significance of margin status and margin width is still controversial. This study serves to further elucidate the role of them. METHOD: This is a retrospective cohort from the Queen Mary Hospital, The University of Hong Kong. Consecutive patients diagnosed to have ICC and with surgical resection performed in curative intent were retrieved, while patients with cholangiohepatocellular carcinoma, Klaskin tumor, tumor of extrahepatic bile duct, and uncertain tumor pathology were excluded. RESULTS: From 1991 to 2013, there were 107 patients underwent hepatectomy for ICC. Gender predilection was not observed with 58 males and 49 females, median age of the patients was 61. The median tumor size was 6 cm and most of them (43%) were moderately differentiated adenocarcinoma. Clear resection margin were achieved in 95 patients (88.8%) and the median margin width was 0.5 cm. The hospital length of stay and operative mortality were 11 days and 3%, respectively. The disease-free survival and overall survival were 17.5 and 25.1 months, respectively. Multivariate analysis showed that margin width was an independent factor associated with disease-free survival (P = 0.015, 95% confidence interval [CI] 0.4-0.9). Subgroup analysis in patients with solitary tumor showed that margin width is an independent factor affecting overall survival (P = 0.048; odds ratio: 0.577; 95% CI: 0.334-0.996). Discriminant analysis showed that the overall survival increased from 36 to 185 months when margin width was >0.9 cm (P = 0.025) in patients with solitary tumor. CONCLUSION: Aggressive resection to achieve resection margin of at least 1 cm maximizes chance of cure in patients with early ICC.