Local infiltration versus laparoscopic-guided transverse abdominis plane block in laparoscopic cholecystectomy: double-blinded randomized control trial.

BACKGROUND: Transverse abdominal plane block (TAP) is a new technique of regional block described to reduce postoperative pain in laparoscopic cholecystectomy (LC). Recent reports describe an easy technique to deliver local anesthetic agent under laparoscopic guidance. METHODS: This randomized control trial was designed to compare the effectiveness of additional laparoscopic-guided TAP block against the standard full thickness port site infiltration. 45 patients were randomized in to each arm after excluding emergency LC, conversions, ones with coagulopathy, pregnancy and allergy to local anesthetics. All cases were four ports LC. Interventions-Both groups received standard port site infiltration with 3-5 ml of 0.25% bupivacaine. The test group received additional laparoscopic-guided TAP block with 20 ml of 0.25% bupivacaine subcostally, between the anterior axillary and mid clavicular lines. As outcome measures the pain score, opioid requirement, episodes of nausea and vomiting and time to mobilize was measured at 6 hourly intervals. RESULTS: The two groups were comparable in the age, gender, body mass index, indication for cholecystectomy difficulty index and surgery duration. The pain score at 6 h (P = 0.043) and opioid requirement at 6 h (P = 0.026) was higher in the TAP group. These were similar in subsequent assessments. Other secondary outcomes were similar in the two groups. CONCLUSION: Laparoscopic-guided transverses abdominis plane block using plain bupivacaine does not give an additional pain relief or other favorable outcomes. It can worsen the pain scores. Pre registration: The trial was registered in Sri Lanka clinical trial registry-SLCTR/2016/011 ( http://www.slctr.lk/trials/357 ).

Association of Serum Ferritin with Diabetes and Alcohol in Patients with Non-Viral Liver Disease-Related Hepatocellular Carcinoma.

INTRODUCTION: Non-alcoholic fatty liver disease is a leading cause for hepatocellular carcinoma (HCC) in Sri Lanka. Diabetes mellitus, alcohol abuse, and liver inflammation are known to increase the risk of HCC. The present study evaluates serum ferritin levels in a cohort of patients with non-viral HCC (nvHCC). METHODOLOGY: Consecutive patients with nvHCC presenting to the Colombo North Liver transplant Service, Ragama, from January 2012 to July 2013 were investigated. All were negative for hepatitis B and C. At registration, 5 mL of serum was separated into plain tubes, stored at -80°C and analysed for ferritin using an enzyme-linked immunosorbent assay. Correlation between the serum ferritin and patient risk factors, liver status, and tumour characteristics were analysed. RESULTS: There were 93 patients with nvHCC (median age 65 [12-82] years; 82 [88.2%] males). The median ferritin level was 246.2 µg/L, and 38 (40.86%) patients had elevated ferritin. Non-diabetics (median 363.5 mg/L, p = 0.003) and alcohol abusers (median 261.2 mg/L, p = 0.018) had higher ferritin levels. On multiple-variable analysis, being non-diabetic (p = 0.013) and alcoholic (p = 0.046) was significantly associated with high serum ferritin. No association was found with body mass index, tumour stage, size, macrovascular invasion, number of nodules, alpha-fetoprotein, bilirubin, international normalized ratio, and survival. CONCLUSION: In patients with nvHCC, serum ferritin levels are higher in non-diabetics and alcoholics.

Diffuse-Type Hepatoma: A Grave Prognostic Marker.

BACKGROUND: Data on diffuse-type hepatocellular carcinoma (HCC) are rare. HCC in Sri Lanka is rising, and the majority is related to nonalcoholic fatty liver disease. This study was planned to compare nodular- and diffuse-type HCC in this cohort. METHODS: CT scans of 227 patients with HCC negative for infective hepatitis were analyzed and grouped as nodular and diffuse from July 2011 to July 2014. Diffuse-type cancer was defined as a tumor without convex/distinct margin, diffusely infiltrating the hepatic parenchyma. There were 45 (20%) cases. The baseline liver functions, etiology, treatment, and the outcome were compared with nodular-type cancers. Stage III diffuse cancers were matched with 2 stage III nodular cancers looking at the T stage and background liver. RESULTS: There was no difference in the age (63 vs. 62 years, p = 0.937) and gender. Diffuse cancers had a low BMI (24 vs. 22, p = 0.009), a higher alpha fetoprotein (AFP) level (p < 0.001), a higher incidence of major vascular invasion (14 vs. 80%, p < 0.001), and a history of significant alcohol consumption (39 vs. 67%, p = 0.001). The baseline liver functions were similar in diffuse and nodular cancers. A large proportion (27 vs.77%, p < 0.001) of diffuse cancers were not candidates for active treatment. Overall survival was poor in the diffuse type (4.7 vs. 25 months, p < 0.001). Diffuse-type stage III cancers had a poor survival compared to matched nodular cancers (2.5 vs. 15.8 months, p = 0.001). CONCLUSION: HCC without a background of infective hepatitis were common in our cohort. These tumors are associated with high AFP levels, major vascular invasion, and a poor prognosis.

Recurrence of graft steatosis after liver transplantation for cryptogenic cirrhosis in recently commenced liver transplant program.

Non-alcoholic fatty liver disease (NAFLD) seems to recur in at least one third of patients transplanted for non-alcoholic steatohepatitis (NASH)-related cirrhosis. While, NASH recurrence does not seem to affect overall graft and patient survival up to 10 years, cardiovascular and infection-related morbidity and mortality seem to be increased in these patients. This report looks at the graft histology in patients who were transplanted for NASH-related cirrhosis after short-term follow up. We report a high prevalence of recurrent NAFLD in liver grafts post-transplant among five patients. The degree of steatosis noted among the recipients is alarming.

Clinical characteristics and outcome of hepatocellular carcinoma in alcohol related and cryptogenic cirrhosis: a prospective study.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is becoming a leading cause of chronic liver disease. Hepatocellular carcinoma (HCC) is one of its complications. Although the pathophysiology is unclear, it is reasonable to expect that cryptogenic cirrhosis related HCC (cryptogenic HCC) behaves differently to other types of HCC. This study prospectively compared patients with cryptogenic HCC and those with HCC related to alcoholic cirrhosis. METHODS: A total of 150 consecutive patients with HCC (89 cryptogenic HCC and 61 alcohol related HCC) referred to our unit over a 23-month period were studied. Their demographic data, liver function, tumor characteristics and outcomes were compared. RESULTS: Alcohol related HCC was seen only in males. Compared with cryptogenic HCC, alcohol related HCC had significantly higher aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio (1.7 vs 1.4, P=0.002), model for end-stage liver disease score (13 vs 11, P=0.018) and Child's score (7 vs 6, P=0.037). No significant difference was seen in platelet counts, serum sodium and AST to platelet ratio index. Single nodular tumors were more common in cryptogenic HCC, while diffuse type tumors and macroscopic vascular invasion were common in alcohol related HCC. In patients who could not be offered any treatment because of advanced tumors or poor liver function, alcohol related HCC had a significantly lower median survival (5.3 months) compared with cryptogenic HCC (9.3 months, P=0.034). CONCLUSIONS: Compared with cryptogenic HCC, alcohol related HCC had worse liver function and aggressive tumor morphology at presentation, and a higher proportion was untreatable. In patients who could not be treated, median survival was lower in patients with alcohol related HCC than in those with cryptogenic HCC.

Effects of donor steatosis on liver biochemistry and significance of body mass index in predicting steatosis.

BACKGROUND: Hepatic steatosis is a major concern in living donor liver transplantation. Factors affecting hepatic functional status after a donor right hepatectomy (with the middle hepatic vein included in the graft) with a focus on changes owing to steatosis were retrospectively studied. METHODS: Donors (n = 325) were categorized into three groups: G0 (no steatosis, n = 178), G1 (< = 10% steatosis, n = 128) and G2 (>10% steatosis, n = 19). Donors with >20% steatosis were excluded. Changes in aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin levels and prothrombin time (PT) were assessed. Factors predicting steatosis were also assessed. A liver biopsy was performed on selected donors. RESULTS: The ALT level rose until day 3 in G1 and day 6 in G2 (P < 0.05). The AST level rose until day 7 in G2 (P < 0.05) but stayed unchanged in G1. The bilirubin level was higher only on day 1 in G2 (P < 0.05). By day 30, no significant difference between any groups was noted. Receiver-operating characteristic (ROC) area under the curve for body mass index (BMI) on predicting steatosis was 0.75 [confidence interval (CI) = 69-80]. Among donors with a BMI > 23.5 kg/m(2), 75% had steatosis. Five donors had >20% steatosis and were not assessed. CONCLUSION: Using a liver with up to 20% steatosis in right liver donation, even if the middle hepatic vein is included in the graft, is safe. For Asian donors, a BMI > 23.5 kg/m(2) is a guide in deciding whether to perform a liver biopsy for steatosis.

Role of portal vein embolization in hepatocellular carcinoma management and its effect on recurrence: a case-control study.

BACKGROUND: Liver regeneration that occurs after portal vein embolization (PVE) may have adverse effects on the microscopic tumor foci in the residual liver mass in patients with hepatocellular carcinoma (HCC). METHODS: Fifty-four HCC patients with inadequate functional residual liver volume were offered PVE during a seven-year period. Among them, 34 (63%) patients underwent curative resection. They were compared with a matched control group (n = 102) who underwent surgery without PVE. Postoperative complications, pattern of recurrence, and survival were compared between groups. RESULTS: In the PVE group, a pre-embolization functional residual liver volume of 23% (12-33.5%) improved to 34% (20-54%) (p = 0.005) at the time of surgery. When the two groups were compared, minor (PVE, 24%; control, 29%; p = 0.651) and major (PVE, 18%; control, 15%; p = 0.784) complications were similar. After a follow-up period of 35 months (standard deviation 25 months), extrahepatic recurrences were detected in 10 PVE patients (29%) and 41 control patients (40%) (p = 0.310). Intrahepatic recurrences were seen in 10 (29%) and 47 (46%) cases (p = 0.109) in the PVE and control groups, respectively. In the PVE group, 41% (n = 14) of the recurrences were detected before one year, compared with 42% (n = 43) in the control group (p = 1). Disease-free survival rates at 1, 3, and 5 years were 57, 29, and 26% in the control group and 60, 42, and 42% in the PVE group (log-rank, p = 0.335). On multivariate analysis, PVE was not a factor affecting survival (p = 0.821). CONCLUSIONS: Portal vein embolization increases the resectability of initially unresectable HCC due to inadequate functional residual liver volume, and it has no deleterious oncological effect after major resection of HCC.

Laparoscopy as a diagnostic and therapeutic option in evaluating chronic unexplained right iliac fossa pain.

BACKGROUND: Management of chronic right iliac fossa (CRIF) pain is poorly documented in literature. No guidelines are available on the best therapeutic approach. METHOD: Patients presenting from October 2007 to August 2009 with pain persisting or recurring in right lower abdomen over a period of 6 weeks or more were assessed. Severity of CRIF pain was documented using a ten-point visual analogue scale. Initial history and examination were followed by urine analysis, blood counts, X-ray and ultrasound scan of the abdomen. Full colonoscopy was performed in all negative cases. Diagnostic or therapeutic laparoscopy was offered to patients with normal initial investigations. The normal-looking appendix was removed in the absence of other positive laparoscopic findings. Patient's immediate complications, pain score at 8 weeks and histology of appendix were assessed. RESULTS: Nineteen patients with median age of 43 years (range 32-52 years) underwent laparoscopy. All were female. Median pain score was 5 (range 4-6). During surgery, 12 (64%) had positive findings. Of these, 6 (30%) had adhesions, which were separated. Three patients with congested appendices were removed. One caecal perforation, tubal mass and ovarian cyst were treated laparoscopically. Seven (36%) patients who had macroscopically normal appendices underwent appendicectomy. There were no immediate postoperative complications. Significant improvement was seen in overall pain score after surgery (median 5, range 4-6 versus median 0, range 0-6; p = 0.001). However, only 57% of patients with normal appendix had improved pain scores (median 5, range 4-6 versus median 1, range 0-6; p = 0.12). All patients with positive laparoscopic findings improved after surgery. CONCLUSION: Laparoscopy seems effective in evaluation and treatment of CRIF pain. The role of appendicectomy with normal-looking appendix needs further evaluation.