Impact of Hypothyroidism on Patients with Hepatocellular Carcinoma Undergoing Liver Transplantation.

BACKGROUND: This work endeavored to explore the effect of hypothyroidism on mortality in subjects with HCC who underwent living-donor liver transplantation (LDLT). METHODS: This prospective study included 107 patients with HCC subjected to LDLT, divided into hypothyroid group (n=53) and euthyroid group (n=54). The primary objectives were overall and disease-free survival (DFS). RESULTS: Euthyroid and hypothyroid groups were comparable in all baseline characteristics except the age of patients. Overall survival (OS) of the whole group at 48 months was 68.8%, while the DFS was 60.2%. On univariate analysis, OS was negatively affected by the older age of the patients (p<0.001) or the donor (p<0.001), hypothyroidism (p=0.008), HBV (p=0.029), larger tumor size (p=0.023), and defective Milan criteria (p=0.022). On multivariate analysis, the age of the patients and donors was the independent factor affecting OS. On univariate analysis, DFS was negatively affected by older age of the patients (p < 0.001) or the donor (p=0.005), hypothyroidism (p=0.005), HBV (p=0.019), larger tumor size (p=0.023), and defective Milan criteria (p=0.020). On multivariate analysis, the age of the patients, thyroid status, and Milan criteria were the independent factors affecting DFS. CONCLUSION: Hypothyroidism is a risk factor for worse outcomes in HCC patients after liver transplantation.

Impact of Sarcopenia on Two-Year Mortality in Patients with HCV-Associated Hepatocellular Carcinoma After Radiofrequency Ablation.

PURPOSE: Radiofrequency ablation (RFA) appears effective for the treatment of hepatocellular carcinoma (HCC). Evaluation of prognostic factors is imperative for patient selection and improving treatment efficacy. This study aimed to assess sarcopenia as a predictor of the outcome of RFA in patients with HCC. METHODS: This prospective study included all patients with HCC on top of HCV-related cirrhosis who underwent RFA and followed up for a minimum of two years. CT scan was used to determine the skeletal muscle index at the psoas, erector spinae, quadratus lumborum, transversus abdominis, external and internal obliques, and rectus abdominis muscles. Cross-sectional areas were calculated to obtain a lumbar skeletal muscle index (L3-SMI). RESULTS: A total of 97 patients were enrolled in the study. The L3-SMI was 46.2±12.1 cm2/m2. Older age was the only risk factor associated with sarcopenia (p = 0.001). The overall survival at two years for the whole group was 65.2%. Sarcopenia and MELD score were independent predictors of OS at two years with HR of 7.6 (95% CI: 3.1-18.7) and 2.2 (95% CI: 1.0-4.8), respectively. Recurrence-free survival was 84.1% at two years. Recurrence was not affected by all factors, including sarcopenia. CONCLUSION: Sarcopenia is a surrogate predictor of overall survival at two years in HCC patients after RFA. Sarcopenia assessment might be an additional prognostic indicator with conventional biomarkers to optimize the selection criteria for receiving RFA for early-stage HCC.

Laparoscopic Sleeve Gastrectomy on the Horizon as a Promising Treatment Modality for NAFLD.

INTRODUCTION: Nonalcoholic fatty liver disease (NAFLD) is viewed as the hepatic manifestation of the metabolic syndrome with hepatic fatty infiltration is the common liver pathology. NAFLD can lead to nonalcoholic steatohepatitis (NASH), liver cirrhosis, liver cell failure, and liver malignancy.The present work aims to prospectively study the histological changes that occur in NAFLD obese patients 1-year post-laparoscopic sleeve gastrectomy (LSG) based on standardized NAS (NAFLD activity score). PATIENTS: This prospective study included 94 obese patients who underwent laparoscopic sleeve gastrectomy. Intraoperative wedge liver biopsy was taken from all patients with a follow-up liver biopsy at 12 months after the operation. RESULTS: LSG produced a marked reduction in body weight with a mean reduction in BMI from 44.54 + 5.45 to 34.23 + 2.66 kg/m2 at 12 months. There were statistically highly significant improvements regarding metabolic comorbidities, blood pressure, lipid profile, and HbA1C at 12-month post-LSG (P < 0.001). The current study showed a highly statistically significant improvement at 1-year post LSG regarding steatosis grade, hepatocyte ballooning, lobular inflammation as well as fibrosis stage (P < 0.001). Moreover, the present study showed that NAS score significantly decreased from 5.20 + 1.96 at baseline to 2.63 + 1.55 at 1-year follow-up (P < 0.001). CONCLUSION: Our relatively large patient cohort shows a significant improvement of steatosis, steatohepatitis, and fibrosis at a 1-year follow-up. LSG can lead to resolution of NAFLD, and it may be in the near future another routine indication for bariatric surgery.

Early application of haemostatic powder added to standard management for oesophagogastric variceal bleeding: a randomised trial.

BACKGROUND: Acute variceal bleeding (AVB) requires early therapeutic management by experienced endoscopists that often poses logistical challenges for hospitals. We assessed a different management concept with early application of haemostatic powder-which does not require high endoscopic expertise-added to conventional management in a randomised trial. METHODS: Cirrhotic patients with AVB received standard medical therapy and were randomised to either immediate endoscopy with haemostatic powder application within 2 hours of admission, followed by early elective endoscopy on the next day, that is, within 12-24 hours of admission for definitive treatment (study group) or to early elective endoscopy only (control group). In both groups, failures to achieve clinical haemostasis until the time of early elective endoscopy underwent rescue endoscopy with attempted conventional haemostasis. Primary outcome was endoscopic haemostasis at the elective endoscopy. RESULTS: Of 86 randomised patients with AVB, 5/43 in the study group required rescue endoscopy for failure of controlling spurting bleeding (n=4) after powder application or for early bleeding recurrence in one patient who died before repeating rescue endoscopy. In the control group, 13/43 patients required rescue endoscopic haemostasis for failure of clinical haemostasis (12%vs30%, p=0.034). In the remaining patients, early elective endoscopic haemostasis was achieved in all 38 patients in the study group, while all remaining 30 patients in the control group had fresh gastric blood or (10%) spurting bleeding at early elective endoscopy with successful haemostasis in all of them. Six-week survival was significantly improved in the study group (7%vs30%, p=0.006). CONCLUSION: The new concept of immediate powder application improves early clinical and endoscopic haemostasis. This simplified endoscopic approach may have an impact on early and 6-week survival. TRIAL REGISTRATION NUMBER: NCT03061604.

Management of acute variceal bleeding using hemostatic powder.

BACKGROUND AND OBJECTIVES: This study aimed to test the safety and efficacy of Hemospray® for emergency control of acute variceal bleeding (AVB) due to portal hypertension in cirrhotic patients. PATIENTS AND METHODS: This single-arm, prospective trial, conducted at two hospitals in Belgium and Egypt, included patients admitted to the emergency room with hematemesis and/or melena and known or suspected liver cirrhosis. All patients received urgent hemodynamic stabilization, octreotide (50 mcg bolus then 25 mcg/hour for 24 hours) and intravenous ceftriaxone (1 g/hour). Endoscopy to confirm AVB and Hemospray® application (if indicated) was performed within six hours of admission. Patients were kept under observation for 24 hours and underwent second endoscopy and definitive therapy (band ligation and/or cyanoacrylate injection in cases of gastric varices) the next day. RESULTS: Thirty-eight patients were admitted for suspected AVB, and 30 of these had confirmed AVB (70% male; mean age 59.5 years (range, 32.0-73 years)). Child-Pugh class C liver disease was present in 53.4%. Esophageal varices were observed in 83.4% of patients, gastric varices in 10%, and duodenal varices in 6.6%. Spurting bleeding at the time of endoscopy was observed in 43.4%. One patient developed hematemesis six hours after Hemospray® application and underwent emergency endoscopic band ligation. No major adverse events or mortalities were observed during 15-day follow-up. CONCLUSION: Hemospray® application was safe and effective at short-term follow-up for emergency treatment of AVB in cirrhotic patients.

Endoscopic treatment of acute variceal hemorrhage by using hemostatic powder TC-325: a prospective pilot study.

BACKGROUND: Current standard of care of acute variceal bleeding (AVB) combines hemodynamic stabilization, antibiotic prophylaxis, pharmacological agents, and endoscopic treatment. The latter may be challenging in an emergency setting with active bleeding that interferes with visualization. OBJECTIVE: To assess the effectiveness of a pre-established delivery protocol of a hemostatic powder to control AVB originating from the esophagus or the gastroesophageal junction. DESIGN: Prospective, 2-center study. SETTING: Two tertiary-care referral university hospitals. PATIENTS: Nine patients who received endoscopic hemostatic powder for actively bleeding varices. INTERVENTIONS: Endoscopic hemostasis. MAIN OUTCOME MEASUREMENT: Primary hemostasis and rebleeding rates. RESULTS: Nine consecutive patients with confirmed AVB underwent treatment within 12 hours of hospital admission. Bleeding stopped during the endoscopy performed with application of 21 g of hemostatic powder from the cardia up to 15 cm above the gastroesophageal junction. No rebleeding was observed in any of the patients within 24 hours. No mortality was observed at 15-day follow-up. LIMITATIONS: Small sample size. CONCLUSION: Hemostatic powder has the potential to temporarily stop AVB. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT01783899.)