Liver transplantation for hepatocellular carcinoma: the Kyoto experience

Background/purpose

The results of living donor liver transplantation (LDLT) for hepatocellular carcinoma (HCC) at Kyoto University were analyzed.

Methods

Between February 1999 and December 2006, 136 patients with HCC underwent LDLT. Of these, 74 patients met the Milan criteria, while 62 patients did not. Treatment for HCC had been previously performed prior to LDLT for 101 patients (74%).

Results

According to the results of multivariate analysis of risk factors for recurrence among preoperative tumor variables, we have defined new Kyoto criteria as ≤10 tumors all ≤5 cm in diameter and protein induced by vitamin K absence or antagonist-II (PIVKA-II) ≤400 mAU/ml. The 5-year recurrence rate was significantly lower for the 85 patients who met the Kyoto criteria than for the 45 patients who exceeded them (3 vs. 54%, p < 0.0001). Similarly, patients who met the Kyoto criteria showed a significantly better 5-year survival rate (87%) than those who did not (36%, p < 0.0001). Survival rates did not differ between pretreated and primary groups, and recurrence rates were similarly low when limited to patients who met the Kyoto criteria.

Conclusions

The proposed Kyoto criteria are expected to serve efficiently as expanded selection criteria for LDLT in patients with HCC. History of previous treatments did not affect outcomes after LDLT.     

Laparoscopic liver resection for treating recurrent hepatocellular carcinoma

Background

It is still unknown whether laparoscopic liver resection is suitable for recurrent hepatocellular carcinoma (HCC) after previous curative hepatic resection.

Method

The perioperative outcomes of 40 patients treated with second surgery for recurrent HCC by partial hepatectomy were studied retrospectively. The second surgery was performed under laparotomy in 20 patients (laparotomy group) and under laparoscopy in 20 patients (laparoscopy group).

Results

Intraoperative blood loss (p < 0.0001) and the incidence of postoperative complications (p = 0.0004) were lower in the laparoscopy group than in the laparotomy group. The incidence rates of surgical site infection and intractable ascites were significantly higher in the laparotomy group than in the laparoscopy group (p = 0.0202, p = 0.0436, respectively). The proportion of patients classified as Clavien grade IIIa was higher in the laparotomy group than in the laparoscopy group (p = 0.0033). The duration of the postoperative hospital stay was significantly shorter in the laparoscopy group than in the laparotomy group (p < 0.0001).

Conclusions

Postoperative morbidity has been decreased by the introduction of laparoscopic liver resection in patients with recurrent HCC after curative hepatic resection. As a result, the duration of the postoperative stay is shorter.     

Assessment of safety in hepatic resection for hepatocellular carcinoma focusing on indirect hyperbilirubinemia

Background/purpose

The indications for hepatic resection for hepatocellular carcinoma (HCC) patients with total bilirubin (T-Bil) equal to or higher than 1.2 mg/dl remain controversial. The aim of this study was to investigate the safety of hepatic resection for HCC patients who showed high T-Bil (≥1.2 mg/dl) with low direct bilirubin (D-Bil ≤ 0.5 mg/dl).

Methods

Thirty-four HCC patients showing high T-Bil with low D-Bil were treated with mono- to tri-segmentectomy between January 2000 and December 2010. The perioperative clinical parameters and prognosis of the high T-Bil/low D-Bil patients were compared with those of 253 HCC patients showing normal T-Bil. In addition, complication rates of the patients with high T-Bil/high D-Bil (n = 4) were analyzed.

Results

The prothrombin time activity, indocyanine green clearance test, asialo-scintigraphy, and platelet count were similar in the two groups. The mean serum albumin in high T-Bil/low D-Bil patients was significantly higher than that of normal T-Bil patients (4.2 ± 0.5 vs. 4.0 ± 0.4 g/dl, P = 0.004). There were no significant differences in operation time, intraoperative bleeding, red cell concentrate transfusion rate, postoperative complication rate, and disease-free and overall survivals between the two groups. Postoperative hyperbilirubinemia (T-Bil >5 mg/dl) with ascites was observed in one of four high T-Bil/high D-Bil patients (25 %).

Conclusions

Mono- to tri-segmentectomy can be performed in patients with low D-Bil (≤0.5 mg/dl) similarly to patients with low T-Bil (<1.2 mg/dl), even in HCC patients showing high T-Bil (≥1.2 mg/dl).     

Graft size and donor age are independent factors for graft loss in adult-to-adult living-donor liver transplantation using the left liver

Background/purpose

Graft survival is affected by various factors, such as preoperative state and the ages of the recipient and donor, as well as graft size. The objective of this study was to analyze the risk factors for graft survival.

Methods

From September 1997 to July 2005, 24 patients who had undergone living-donor liver transplantation (LDLT) were retrospectively analyzed. Sixteen patients survived and the eight graft-loss cases were classified into two groups according to the cause of graft loss: graft dysfunction without major post-transplantation complications (graft dysfunction group; n = 3), and graft dysfunction with such complications (secondary graft dysfunction group; n = 5). Various factors were compared between these groups and the survival group.

Results

Mean donor age was 31.9 years in the survival group and 49.2 years in the secondary graft dysfunction group (P = 0.024). Graft weight/recipient standard liver volume ratios (G/SLVs) were 36.7% in the survival group, and 26.2% in the graft dysfunction group (P = 0.037). The postoperative mean PT% for 1 week was 48.6% in the survival group and 38.1% in the secondary graft dysfunction group (P = 0.05).

Conclusions

Our surgical results demonstrated that G/SLV and donor age were independent factors that affected graft survival rates.     

Equivalent Outcomes After Anatomical and Non-anatomical Resection of Small Hepatocellular Carcinoma in Patients with Preserved Liver Function

Background

Although anatomical resection (AR) is considered better than non-anatomical resection (NAR) for the treatment for hepatocellular carcinoma (HCC), there is only limited evidence in support of this argument.

Aim

The aim of this study was to investigate whether AR is superior to NAR regarding postoperative outcomes in patients with small solitary HCC and preserved liver function.

Methods

The study subjects were 92 curatively-resected patients with adequate liver function reserve (indocyanine green retention rate at 15 min <15%, prothrombin time >70%, serum albumin >3.5 g/dl) and macroscopically small (≤3.0 cm) solitary HCC without macroscopic vascular invasion; 30 patients underwent AR and 62 patients NAR. Postoperative short-term outcomes including mortality and morbidity and long-term outcomes were compared in the two groups.

Results

There was no significant difference in clinicopathological background in the two groups. Although resected liver volume was significantly larger in the AR group than the NAR group (p < 0.0001), no significant differences were detected in the incidence of mortality or morbidity. For long-term outcomes, there were no significant differences between the two groups in disease-free survival or overall survival. Multivariate analysis showed that the extent of surgical procedure was not a significant prognostic factor for disease-free or overall survival.

Conclusions

AR of a solitary small HCC did not carry postoperative outcome advantages compared with NAR in patients with preserved liver function. We recommend NAR for hepatic resection of small solitary HCC in patients with preserved liver function.     

Long-term outcome of ABO-incompatible living-donor liver transplantation: a single-center experience

Purpose

We report the long-term outcome of ABO-incompatible living donor liver transplantation (LDLT) performed in our hospital.

Methods

We started the LDLT program in 1991 and from that year up to now (2008) 11 patients have received an ABO-incompatible graft.

Results

Nine out of the 11 cases have survived from 3.7 years to 13.9 years (mean 7.3 years) and they are in good conditions at present. Seven patients were subjected to preoperative apheresis. Eight patients experienced acute rejection and of them, 6 experienced steroid-resistant rejection that was treated with deoxyspergualin and apheresis. One patient who suffered rapidly progressing rejection died due to liver failure. Three patients who were administered rituximab did not suffer severe rejection nor adverse effects. During the long-term follow up 5 recipients had major complications such as postoperative lymphoproliferative disease, post-transplantation diabetes mellitus, portal vein occlusion and biliary stenosis. But those complications were controlled under stable conditions.

Conclusions

We concluded that long-term survival can be expected after ABO-incompatible LDLT provided perioperative complications such as humoral rejection are overcome.     

Strategies to treat interferon-induced graft dysfunction after living donor liver transplantation for hepatitis C

Purpose

Interferon-induced graft dysfunction (IGD) is a poorly defined, unrecognized, but potentially serious condition for patients receiving antiviral drugs after liver transplantation for hepatitis C.

Methods

We evaluated the characteristics of 80 patients who received pegylated interferon-based antiviral treatment for hepatitis C after living donor liver transplantation (LDLT).

Results

Eight patients experienced IGD either during (n = 6) or after completing (n = 2) antiviral treatment. Pathological diagnosis included acute cellular rejection (ACR, n = 1), plasma cell hepatitis (PCH, n = 2), PCH plus ACR (n = 3), and chronic rejection (CR, n = 2). One patient with CR initially presented with PCH plus ACR and the other presented with ACR; both had apparent cholestasis. The six patients with ACR or PCH without cholestasis were successfully treated by discontinuing antiviral treatment and increasing immunosuppression, including steroids. By contrast, both of the patients with CR and cholestasis experienced graft loss, despite aggressive treatment. Univariate analysis showed that pegylated interferon-α2a-based treatment (75 vs. 26.4 %, p < 0.01) was the only significant factor for IGD, and was associated with decreased 5-year graft survival (93.4 vs. 71.4 %, p = 0.04).

Conclusions

IGD is a serious condition during or even after antiviral treatment for hepatitis C after LDLT. Early recognition, diagnosis, discontinuation of interferon, and introduction of steroid-based treatment may help to save the graft.     

The introduction of a simple maneuver to reduce the risk of postoperative bleeding after major hepatectomies

Background/Purpose

In major hepatectomies, postoperative increases in central venous pressure (CVP) may cause suture failure and massive bleeding. The aim of our study is to test the application of an intraoperative maneuver to reduce the risk of postoperative bleeding.

Methods

Our study included 172 consecutive patients who had major liver resection with selective hepatic vascular exclusion and sharp transection of the liver parenchyma. An intraoperative maneuver (5 s occlusion of the hepatic vein) was applied in an alternating way, and the patients were assigned to two groups: Cohort A (n = 86), that was granted the maneuver, and Cohort B (n = 86), that was used as a control group.

Results

In Cohort A, application of the maneuver was successful in demonstrating bleeders under low CVP levels. Cohort A had lower rate of massive bleeding requiring emergency reoperation (2.3 vs 5.8%, P = 0.049), less postoperative blood transfusions (13 vs 24%, P = 0.042), lower morbidity (20 vs 35%, P < 0.045) and shorter hospital stay compared to Cohort B.

Conclusions

Hepatectomies conducted under low CVP are prone to postoperative hemorrhage which can be prevented if the final bleeding control is performed under high pressure in the hepatic veins. Application of our testing maneuver effectively unmasked previously undetectable bleeding veins.     

Postoperative arterial blood lactate level as a mortality marker in patients with colorectal perforation

Purpose

This study aims to assess the clinical relevance of postoperative arterial blood lactate (LAC) level as a prognostic factor in patients with colorectal perforation.

Methods

Forty-two patients (22 males, 20 females; mean age, 70.8 years) underwent emergency surgery for colorectal perforation. The patients were divided into mortality and survivor groups. As a prognostic scoring system, Acute Physiological and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA), and Systemic Inflammatory Response Syndrome criteria were calculated. These scores, postoperative LAC level, and other data, including site and etiology of perforation, elapsed time from onset to surgery (eTIME), preoperative white blood cell (WBC) and platelet counts, preoperative C-reactive protein (CRP), and preoperative arterial blood base excess were assessed between the groups.

Results

The total mortality rate was 33.3 %. On univariate analysis, the APACHE-II and SOFA scores were significantly higher, and eTIME was significantly longer in the mortality group than in the survivor group. The postoperative LAC level was significantly higher in the mortality group (43.1?±?14.1 mg/dl) than in the survivor group (23.8?±?12.7 mg/dl; p?<?0.001), and the preoperative WBC was significantly lower in the mortality group than in the survivor group. Multivariate logistic regression analysis using the mortality risk factors determined by univariate analysis (eTIME, APACHE-II score, SOFA score, preoperative WBC count, and postoperative LAC) demonstrated that postoperative LAC level was an independent risk factor for mortality.

Conclusions

High postoperative LAC level was a useful factor for predicting high mortality rate in patients with colorectal perforation.     

Branched-chain amino acid-enriched nutrients improve nutritional and metabolic abnormalities in the early post-transplant period after living donor liver transplantation

Background/purpose

Malnutrition and metabolic disorder of patients undergoing living donor liver transplantation (LDLT) can affect post-transplant prognosis. The aim of this study was to establish whether perioperative usage of branched-chain amino-acid (BCAA)-enriched nutrients improve metabolic abnormalities of patients undergoing LDLT.

Methods

We designed a randomized pilot study (UMIN registration number; 000004323). Twenty-five consecutive adult elective LDLT recipients were enroled and divided into two groups: the BCAA group (BCAA-enriched nutrients, n?=?12) and the control group (standard diet, n?=?13). Metabolic and nutritional parameters, including BCAA-to-tyrosine ratio (BTR), retinol binding protein (RBP), and prealbumin were regularly measured from 1?week before to 4?weeks after LDLT. Non-protein respiratory quotient (npRQ) was measured before and 4?weeks after LDLT.

Results

BTR and RBP improved considerably in the BCAA group compared with the controls. npRQ significantly increased from 1?week before LDLT to 4?weeks after LDLT in the BCAA group (0.77?±?0.05 to 0.84?±?0.06, P?=?0.002), but not in the control group (0.78?±?0.04 to 0.81?±?0.05).

Conclusions

Supplementation with BCAA-enriched nutrients might improve persistent nutritional and metabolic disorders associated with end-stage liver disease in the early post-transplant period, and consequently shorten the post-transplant catabolic phase after LDLT. A larger multicenter trial is needed to confirm these findings.     

New-onset diabetes mellitus developing in Asian adult living donor liver transplant recipients: a single-center experience

Background

New-onset diabetes mellitus (NODM) after liver transplantation is a common complication with a potentially negative impact on patient outcome.

Methods

To evaluate the incidence of NODM and its impact on Asian adult living donor liver transplant (LDLT) recipients, we investigated 369 adult LDLT cases in our institute.

Results

Preoperative diabetes mellitus (DM) was diagnosed in 38 (9 %) patients. NODM was observed in 128/331 (38 %) patients, 56 (44 %) with persistent NODM and 72 (56 %) with transient NODM. The mean interval between LDLT and the development of NODM was 0.6 ± 1.8 (range 0–1.4) months. Multivariate analyssis revealed that older age, being male and having a higher body mass index were independent risk factors among recipients for developing NODM, while hepatitis C virus infection was not a significant risk factor, and DM had no impact on patient outcome.

Conclusions

Although the long-term effect of DM on outcome remains to be investigated, the presence of DM after liver transplant, whether it was NODM or preexisting DM, had no impact on LDLT recipients’ outcomes in mid-term.     

Preoperative estimation of asialoglycoprotein receptor expression in the remnant liver from CT/99mTc-GSA SPECT fusion images correlates well with postoperative liver function parameters

Background

Accurate preoperative estimation of remnant liver function is critically important for hepatic surgery, and the expression of asialoglycoprotein receptors (ASGPR) is associated with hepatic function.

Methods

Thirty-two patients with hepatocellular carcinoma who underwent surgical resection were studied. To estimate the expression of ASGPR in the remnant liver, simulated surgery was performed on fusion images that combined data from ^99mtechnetium-galactosyl human serum albumin (^99mTc-GSA)/single photon emission computed tomography (SPECT) and computed tomography (CT) scanning. The liver uptake ratio (LUR) of ^99mTc-GSA and the functional liver volume (FLV) in the remnant liver were predicted and were compared with postoperative liver function parameters.

Results

The LUR of ^99mTc-GSA was strongly correlated with the extent of hepatic ASGPR expression (r = 0.944, p = 5.01 × 10^?16), being confirmed to be a reliable parameter for the evaluation of liver function. The estimated remnant LUR, but not the estimated remnant FLV, was significantly correlated with postoperative liver function parameters, such as serum total bilirubin (r = ?0.430, p < 0.05), prothrombin activity (r = 0.515, p < 0.01), and serum cholinesterase activity (r = 0.546, p < 0.01) at 1 week.

Conclusion

Preoperative estimation of the extent of ASGPR expression in the remnant liver on CT/GSA-SPECT fusion images correlated well with postoperative liver function parameters, suggesting its usefulness for surgical decisions.     

Noninvasive diagnostic method for idiopathic portal hypertension based on measurements of liver and spleen stiffness by ARFI elastography

Background

Acoustic radiation force impulse (ARFI) elastography is an ultrasound technique that is capable of measuring tissue stiffness noninvasively. It is difficult to differentiate idiopathic portal hypertension (IPH) from liver cirrhosis (LC) or chronic hepatitis (CH), and liver biopsy is essential. We investigated whether it would be possible to noninvasively diagnose IPH by measuring the stiffness of the liver and spleen by ARFI.

Methods

The subjects were 17 IPH patients, 25 LC patients, 20 CH patients, and 20 normal controls (NC). We measured liver stiffness, spleen stiffness, and the spleen/liver stiffness ratio, and plotted ROC curves.

Results

The median value of liver stiffness in the IPH group was lower than that in the LC group (p = 0.00077) and about the same as in the CH group (p = 0.79). The median value of spleen stiffness was highest in the IPH group (IPH vs. LC group, p = 0.003; IPH vs. CH group, p < 0.00001). The spleen/liver stiffness ratio was lower in the LC group and in the CH group, and higher in the IPH group (p < 0.001, respectively). When an ROC curve of spleen/liver stiffness ratios was plotted to differentiate between the IPH group and the combined group of patients with other liver diseases (LC + CH group), when a cutoff value of 1.71 was used, the AUROC was 0.933 sensitivity 0.941, specificity 0.800, and accuracy 0.839.

Conclusion

Measuring the spleen/liver stiffness ratio by ARFI made it possible to noninvasively, specifically, and accurately diagnose IPH.     

Radiofrequency-Assisted Versus Clamp-Crushing Parenchyma Transection in Cirrhotic Patients with Hepatocellular Carcinoma: A Randomized Clinical Trial

Background

Surgical resection remains the optimal therapy for cirrhotic patients with hepatocellular carcinoma (HCC) that are not suitable for liver transplantation (LT). Recently, various innovative techniques for liver resection have been developed.

Aim

The aim of the study was to compare radiofrequency-assisted parenchyma transection (RF-PT) with the traditional clamp-crushing (CC) technique to explore the preferred therapy in cirrhotic patients with HCC.

Methods

From January 2009 to December 2010, 75 cirrhotic patients with HCC who underwent hepatectomy were randomized to RF-PT (group 1, n = 38) or CC-PT (group 2, n = 37) groups. The primary endpoint was intraoperative blood loss. The secondary endpoints included hepatic transection time, total operating time, postoperative morbidity, mortality, length of intensive care unit and hospital stays, and liver function.

Results

The characteristics of the two patient groups were closely matched. The Pringle maneuver was not used in RF-PT patients. The blood loss of the RF-PT group, total or during transection, was significantly lower than that of the CC-PT group (385 vs. 545 ml, p = 0.001; 105 vs. 260 ml, p = 0.000, respectively). Compared with CC-PT patients, the morbidity of the RF-PT group was lower though not statistically significant (28.9 vs. 38.8 %, p = 0.197). One death occurred in the RF-PT group 12 days postoperative due to a large area cerebral embolism.

Conclusion

RF-PT is a safe and feasible surgical resection method for patients with cirrhosis and concomitant HCC. In addition, RF-PT results in lower blood loss and lower morbidity than the CC technique during liver resection.     

Laparoscopic liver resection facilitates salvage liver transplantation for hepatocellular carcinoma

Background/Purpose

In patients with hepatocellular carcinoma (HCC), a previous liver resection (LR) may compromise subsequent liver transplantation (LT) by creating adhesions and increasing surgical difficulty. Initial laparoscopic LR (LLR) may reduce such technical consequences, but its effect on subsequent LT has not been reported. We report the operative results of LT after laparoscopic or open liver resection (OLR).

Methods

Twenty-four LT were performed, 12 following prior LLR and 12 following prior OLR. The LT was performed using preservation of the inferior vein cava. Indication for the LT was recurrent HCC in 19 cases (salvage LT), while five patients were listed for LT and underwent resection as a neoadjuvant procedure (bridge resection).

Results

In the LLR group, absence of adhesions was associated with straightforward access to the liver in all cases. In the OLR group, 11 patients required long and hemorrhagic dissection. Median durations of the hepatectomy phase and whole LT were 2.5 and 6.2 h, and 4.5 and 8.3 h in the LLR and OLR groups, respectively (P < 0.05). Median blood loss was 1200 ml and 2300 ml in the LLR and OLR groups, respectively (P < 0.05). Median transfusions of hepatectomy phase and whole LT were 0 and 3 U, and 2 and 6 U, respectively (P < 0.05). There were no postoperative deaths.

Conclusions

In our study, LLR facilitated the LT procedure as compared with OLR in terms of reduced operative time, blood loss and transfusion requirements. We conclude that LLR should be preferred over OLR when feasible in potential transplant candidates.     

Development of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) after pancreaticoduodenectomy: proposal of a postoperative NAFLD scoring system

Background

The main etiology of NAFLD and NASH after pancreatic resection is still unclear, and the therapeutic strategy has yet to be established. The focus of this review is how predict and prevent NAFLD/NASH after pancreaticoduodenectomy.

Methods

From April 2005 to October 2008, 54 patients who underwent pancreaticoduodenectomy in our institution were enrolled in this study. From the pre-, intra- and postoperative risk factors, we identified the most influential risk factors of postoperative NAFLD by uni- and multivariate analyses. Moreover, a postoperative NAFLD scoring system was proposed based on these risk factors.

Results

The incidence of postoperative NAFLD was 37.0% (20/54). Of these, 10% (2/20) of patients were diagnosed as having NASH by percutaneous liver biopsy. By multivariate analysis, pancreatic adenocarcinoma (p < 0.05), pancreatic resection line (p < 0.01) and postoperative diarrhea (p < 0.01) were identified as the most influential factors concerning postoperative NAFLD. Based on these results, we proposed a postoperative NAFLD scoring system (0–10) and evaluated the correlation between the score and decreasing rates of CT values, revealing a significant correlation (r = 0.829 p < 0.001). The prevalence of postoperative NAFLD in the patients with our scores of 0–3, 4–6 and 7–10 points was 0 (0/22), 35 (6/17) and 93% (14/15), respectively.

Conclusions

In conclusion, NAFLD develops frequently in patients who undergo PD, and some patients even progress to NASH. A postoperative NAFLD scoring system makes it possible to predict the occurrence of NAFLD after PD, and aggressive nutrition support is needed for patients with high scores.     

A pancreaticoduodenectomy is acceptable for periampullary tumors in the elderly,even in patients over 80 years of age

Background

Although the mortality rates for pancreaticoduodenectomy have been reported to be low for periampullary tumors at high-volume centers, postoperative results still remain unclear for elderly patients over 80 years of age.

Methods

This was a retrospective study of patients who underwent a pancreaticoduodenectomy and consisted of 335 patients who were treated for periampullary tumors between January 1994 and August 2008. The main outcomes were postoperative complications, mortality, and the length of hospital stay among the elderly patients, and they were analyzed in three groups: elderly patients over 80 years old, septuagenarians, and those under 70 years of age.

Results

The performance status of elderly patients was lower than that of the patients under 70 (P < 0.05), and the elderly had a higher American Society of Anesthesiologists physical status classification score (P < 0.001) as well as low hemoglobin and serum albumin levels (P < 0.01 and P < 0.001, respectively). The incidence of delayed gastric emptying in the elderly was higher; however, there was no significant difference. The other outcomes in the elderly group were similar to those of the other groups.

Conclusions

Pancreaticoduodenectomy was considered to be a feasible surgical procedure for elderly patients who had a good performance status.     

Analysis of risk factors for hyperbilirubinemia occurring after hepatectomy

Background

To further improve the outcomes of liver resection, it is important to identify and prevent the causes of the hyperbilirubinemia occurring after hepatectomy and postoperative liver failure.

Methods

Between 2004 and 2009, 591 consecutive patients underwent a hepatectomy at our center. Twenty-two patients who developed hyperbilirubinemia (postoperative total bilirubin over 5?mg/dL) after hepatectomy were classified as Hi-Bi group and another 569 whose total bilirubin did not increase beyond 5?mg/dL were classified as non-Hi-Bi group.

Results

A preoperative prothrombin test of less than 80% and a blood loss of more than 1000?mL were identified as independent risk factors for the Hi-Bi group by multivariate analysis. The hyperbilirubinemia of 16 cases improved, while that of 6 cases was prolonged. One of these patients died of liver failure without responding to treatment. The mortality rate for postoperative liver failure in this study was 0.16% (1/591).

Conclusion

It is important to reduce the length of surgery and intraoperative blood loss to prevent hyperbilirubinemia after hepatectomy. Additionally, decision-making using our algorithm and full examination of the accurate evaluation results, including those for prothrombin time, residual liver function and liver damage, can help reduce the development of hyperbilirubinemia.     

Lower relapse rates with good post-transplant outcome in alcoholic liver disease: Experience from a living donor liver transplant center

Introduction

Post-transplant relapse is a major factor influencing the long-term outcome in alcoholic liver disease (ALD) patients.

Aims

The aim of this study was to evaluate the relapse rates following living donor liver transplantation (LDLT) in patients with ALD in the Indian context with strong family support.

Methods

Of 458 patients who underwent LDLT for ALD, 408 were included in the study. Post-transplant relapse was determined by information provided by the patient and/or family by means of outpatient and e-mail questionnaire, supported by clinical/biochemical parameters/liver histopathology.

Results

All except one were males, with a mean age of 46.9?±?8.5 years. The overall rate of relapse was 9.5 % at 34.7 months (interquartile range (IQR) 15–57.6), lower than that reported in the literature from the West. The relapse rate was higher in patients with a shorter duration of pre-transplant abstinence (17.4 % and 15.4 % for recipients with pre-transplant abstinence of <3 and <6 months, respectively, p?<?0.05). The overall survival was 88.5 % at 3 years. Of 39 patients with relapse, 16 (41 %) were occasional drinkers, 14 (35.8 %) were moderate drinkers, and 9 (23 %) were heavy drinkers. All the heavy drinkers presented with features of graft dysfunction.

Conclusions

Good results can be obtained following LDLT for ALD, with significantly lower relapse rates in our setup as compared to the West.

     

Novel virtual hepatectomy is useful for evaluation of the portal territory for anatomical sectionectomy, segmentectomy, and hemihepatectomy

Background

The novel technique of virtual hepatectomy is useful for evaluation of the portal territory of the liver, since this software program includes functions for liver surgery planning. We evaluated the accuracy of virtual hepatectomy for anatomical hepatectomy.

Methods

Between 2010 and 2011, 92 patients with liver tumors underwent virtual hepatectomy preoperatively. The predicted liver volume was compared with the actual liver volume among patients who underwent anatomical sectionectomy, segmentectomy, and hemihepatectomy.

Results

Ninety of 92 patients underwent anatomical hepatectomy on the basis of virtual hepatectomy. According to the surgical procedure, the predicted liver resection volume showed a strong correlation with the actual liver volume in patients who underwent sectionectomy (r = 0.985, p < 0.0001, n = 44, median error rate 9 %), segmentectomy (r = 0.949, p < 0.0001, n = 17, median error rate 12 %), and hemihepatectomy (r = 0.967, p < 0.0001, n = 29, median error rate 7 %).

Conclusions

The novel technique of virtual hepatectomy is useful for evaluation of the portal territory for anatomical sectionectomy, segmentectomy, and hemihepatectomy.