Survival analysis of breast cancer liver metastasis treated by hepatectomy: A propensity score analysis for Chinese women in Hong Kong.

BACKGROUND: Survival of patients with breast cancer liver metastasis is very poor. This study aimed to analyze the survival outcome of hepatectomy for this patient population. METHODS: From January 1995 to December 2014, 2522 patients with liver cancer received hepatectomy at our hospital. Twenty-one of them, all female, received the operation for breast cancer liver metastasis. Performance was compared with patients with colorectal liver metastasis treated with hepatectomy after propensity score analysis in a ratio of 1:3. RESULTS: Twenty-one patients received hepatectomy for breast cancer. After propensity score matching, 63 patients who had hepatectomy for colorectal cancer were selected for comparison. There was no significant difference in immediate or short-term outcomes between the two groups of patients in terms of operative time, blood loss and surgical morbidities. All patients with breast cancer had R0 resection. No hospital death occurred. After hepatectomy, the 1-, 3- and 5-year overall survival rates were 100.0%, 58.9% and 58.9% respectively in patients with breast cancer. The 1-, 3- and 5-year overall survival rates were 95.0%, 57.2% and 39.7% respectively in patients with colorectal cancer (P = 0.572). On multivariate analysis, triple negative status was the only independent poor prognostic factor in breast cancer liver metastasis (OR = 6.411; 95% CI: 1.351-30.435; P = 0.019). CONCLUSIONS: Hepatectomy is a safe and effective way of treating breast cancer liver metastasis at experienced centers where multidisciplinary adjuvant treatments are available. It can be considered more frequently as part of the multidisciplinary care for this patient population.

Donor ductal anomaly is not a contraindication to right liver lobe donation.

BACKGROUND: Data of living-donor liver transplantation (LDLT) suggested that donor ductal anomaly may contribute to postoperative biliary complications in recipients and in donors. This retrospective study aimed to determine if the occurrence of postoperative biliary stricture in donors or recipients in right-lobe LDLT (RLDLT) is related to donor biliary anatomy type. METHODS: We analyzed our RLDLT recipients' clinical data and those of their graft donors. The recipients were divided into 2 groups: with and without postoperative biliary stricture. The 2 groups were compared. The primary endpoints were donor biliary anatomy type and postoperative biliary complication incidence; the secondary endpoints were 1-, 3- and 5-year graft and patient survival rates. RESULTS: Totally 127 patients were included in the study; 25 (19.7%) of them developed biliary anastomotic stricture. In these 25 patients, 16 had type A biliary anatomy, 3 had type B, 2 had type C, 3 had type D, and 1 had type E. In the 127 donors, 96 (75.6%) had type A biliary anatomy, 13 (10.2%) had type B, 6 (4.7%) had type C, 10 (7.9%) had type D, and 2 (1.6%) had type E. Biliary stricture was seen in 2 donors, who had type A biliary anatomy. None of the recipients or donors developed bile leakage. No association between the occurrence of postoperative biliary stricture and donor biliary anatomy type was found (P = 0.527). CONCLUSIONS: The incidence of biliary stricture in donors or recipients after RLDLT was not related to donor biliary anatomy type. As postoperative complications were similar in whatever type of donor bile duct anatomy, donor ductal anomaly should not be considered a contraindication to donation of right liver lobe.

Prevention of post-sphincterotomy bleeding by proton pump inhibitor: A randomized controlled trial.

OBJECTIVE: Post-endoscopic sphincterotomy (EST) bleeding is one of the most frequent complications of endoscopic retrograde cholangiopancreatography (ERCP). Although the use of proton pump inhibitors (PPIs) reduces the risk of peptic ulcer bleeding, their role in preventing EST bleeding has not been evaluated. This study aimed to assess the use of pre-emptive PPIs in patients undergoing EST. METHODS: This was an investigator-initiated, open-label, randomized study. Consecutive patients scheduled to undergo ERCP and EST were enrolled after excluding those who had previous EST or used acid-suppression agents. Eligible patients were randomized to receive either PPI or standard care. The PPI group received intravenous esomeprazole 4 h before the EST and then every 12 h for 1 day, followed by high-dose oral esomeprazole for 10 days. All patients were followed up for 30 days. The primary outcome was the proportion of patients with combined immediate and delayed overt post-EST bleeding. RESULTS: Altogether 125 patients (60 in the PPI arm and 65 in the standard care arm) who had undergone EST were analyzed. Immediate bleeding was noted in nine (15.0%) patients in the PPI group and four (6.2%) in the standard care group (P = 0.14). Overt delayed post-EST bleeding was seen in two (3.3%) and five (7.7%) patients in PPI and standard care arms, respectively (P = 0.44). There were no significant differences in other outcomes, including a decrease in hemoglobin of >20 g/L, the need for blood transfusion, length of hospital stay and 30-day mortality. CONCLUSION: Pre-emptive PPI did not reduce the risk of post-EST bleeding.

Hepatopancreatoduodenectomy for advanced hepatobiliary malignancies: a single-center experience.

BACKGROUND: Hepatopancreatoduodenectomy is a complicated and challenging procedure but necessary for curative resection for advanced hepatobiliary malignancies. This retrospective study was to examine the safety and survival outcomes of hepatopancreatoduodenectomy in our center. METHODS: Prospectively collected data of 12 patients who underwent hepatopancreatoduodenectomy for advanced hepatobiliary malignancies in our hospital from January 1998 to December 2014 were analyzed. The primary endpoints are treatment-related morbidity and mortality and the secondary endpoints are overall survival and disease-free survival. RESULTS: Curative resection was achieved in 11 (91.7%) patients. Complications developed in 10 (83.3%) patients. Three hospital deaths resulted from multiorgan failure secondary to postoperative pancreatic fistula or hepaticojejunostomy leakage. Six of the nine remaining patients had disease recurrence. The nine patients had a median survival of 39.8 (5.3-151.8) months. The 1-, 3- and 5-year overall survival rates were 66.7%, 55.6% and 27.8%, respectively. The corresponding disease-free survival rates were 55.6%, 44.4% and 29.6%, respectively. CONCLUSIONS: Morbidity and mortality after hepatopancreatoduodenectomy were significant. With R0 resection, the 5-year overall survival and disease-free survival rates were 27.8% and 29.6%, respectively.

Outcomes of right-lobe and left-lobe living-donor liver transplantations using small-for-size grafts.

AIM: To analyze the outcomes of living-donor liver transplantation (LDLT) using left-lobe (LL) or right-lobe (RL) small-for-size (SFS) grafts. METHODS: Prospectively collected data of adult patients who underwent LDLT at our hospital in the period from January 2003 to December 2013 were reviewed. The patients were divided into the RL-LDLT group and the LL-LDLT group. The two groups were compared in terms of short- and long-term outcomes, including incidence of postoperative complication, graft function, graft survival, and patient survival. A SFS graft was defined as a graft with a ratio of graft weight (GW) to recipient standard liver volume (RSLV) (GW/RSLV) of < 50%. The Urata formula was used to estimate RSLV. RESULTS: Totally 218 patients were included for analysis, with 199 patients in the RL-LDLT group and 19 patients in the LL-LDLT group. The two groups were similar in terms of age (median, 53 years in the RL-LDLT group and 52 years in the LL-LDLT group, P = 0.997) but had significantly different ratios of men to women (165:34 in the RL-LDLT group and 8:11 in the LL-LDLT group, P < 0.0001). The two groups were also significantly different in GW (P < 0.0001), GW/RSLV (P < 0.0001), and graft cold ischemic time (P = 0.007). When it comes to postoperative complication, the groups were comparable (P = 0.105). Five patients died in hospital, 4 (2%) in the RL-LDLT group and 1 (5.3%) in the LL-LDLT group (P = 0.918). There were 38 graft losses, 33 (16.6%) in the RL-LDLT group and 5 (26.3%) in the LL-LDLT group (P = 0.452). The 5-year graft survival rate was significantly better in the RL-LDLT group (95.2% vs 89.5%, P = 0.049). The two groups had similar 5-year patient survival rates (RL-LDLT: 86.8%, LL-LDLT: 89.5%, P = 0.476). CONCLUSION: The use of SFS graft in LDLT requires careful tailor-made surgical planning and meticulous operation. LL-LDLT can be a good alternative to RL-LDLT with similar recipient outcomes but a lower donor risk. Further research into different patient conditions is needed in order to validate the use of LL graft.

Resection of T4 hepatocellular carcinomas with adjacent structures, is it justified?

BACKGROUND: T4 hepatocellular carcinoma (HCC) with invasion to adjacent structure(s) may require resection of not only the tumor but also the invaded structure(s). This study aims to assess whether such combined resection for T4 HCC is justifiable. METHODS: Adult patients with T4 HCC were divided into three groups. Group 1: tumors and invaded adjacent structures were resected together if histopathologically confirmed tumor invasion; group 2: same as group 1 but histopathologically confirmed tumor adhesion; group 3: tumor resection only. Group comparisons were made. RESULTS: Totally 144 patients were included in the study. There were 71, 14 and 59 patients in groups 1, 2 and 3, respectively. The groups were comparable in demographics, complication and survival. Ten hospital deaths occurred (5, 0 and 5 in groups 1, 2 and 3, respectively; P=0.533). The 5-year overall survival (hospital mortality excluded) was 17.8% in group 1, 14.3% in group 2, and 28.9% in group 3 (P=0.191). The 5-year disease-free survival was 10.4% in group 1 and 14.5% in group 3 (no data for group 2 yet) (P=0.565). On multivariate analysis, macrovascular invasion and poor differentiation were risk factors for survival whereas combined resection did not impact patients' survival. CONCLUSIONS: Combined resection achieved survival outcomes similar to tumor resection only. Patients with tumor invasion and those with tumor adhesion had comparable survival after combined resection. At centers with the required expertise, combined resection should be attempted to treat T4 HCCs with clinically suspected invasion of adjacent structures.

Acute pancreatitis induced by transarterial chemoembolization: a single-center experience of over 1500 cases.

BACKGROUND: Acute pancreatitis is a relatively rare but potentially lethal complication after transarterial chemotherapy. This study aimed to review the complications such as acute pancreatitis after transarterial chemotherapy with or without embolization for hepatocellular carcinoma. METHODS: A total of 1632 patients with hepatocellular carcinoma who had undergone transarterial chemoembolization from January 2000 to February 2014 in a single-center were reviewed retrospectively. We investigated the potential complications of transarterial chemoembolization, such as acute pancreatitis and acute pancreatitis-related complications. RESULTS: Of the 1632 patients with hepatocellular carcinoma who had undergone 5434 transarterial chemoembolizations, 1328 were male and 304 female. The median age of these patients was 61 years. Most (79.6%) of the patients suffered from HBV-related hepatocellular carcinoma. The median tumor size was 5.2 cm. Of the 1632 patients, 145 patients underwent transarterial chemoembolization with doxorubicin eluting bead, making up a total of 538 episodes. The remaining patients underwent transarterial chemoembolization with cisplatin. Seven (0.4%) patients suffered from acute pancreatitis post-chemoembolization. Six patients had chemoembolization with doxorubicin and one had chemoembolization with cisplatin. Patients who received doxorubicin eluting bead had a higher risk of acute pancreatitis [6/145 (4.1%) vs 1/1487 (0.1%), P<0.0001]. Two patients had anatomical arterial variations. Four patients developed acute pancreatitis-related complications including necrotizing pancreatitis (n=3) and pseudocyst formation (n=1). All of the 4 patients resolved after the use of antibiotics and other conservative treatment. Three patients had further transarterial chemoembolization without any complication. CONCLUSIONS: Acute pancreatitis after transarterial chemoembolization could result in serious complications, especially after treatment with doxorubicin eluting bead. Continuation of current treatment with transarterial chemoembolization after acute pancreatitis is feasible providing the initial attack is completely resolved.

Strategies to increase the resectability of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is best treated by liver transplantation, but the applicability of transplantation is greatly limited. Tumor resection in partial hepatectomy is hence resorted to. However, in most parts of the world, only 20%-30% of HCCs are resectable. The main reason for such a low resectability is a future liver remnant too small to be sufficient for the patient. To allow more HCC patients to undergo curative hepatectomy, a variety of ways have been developed to increase the resectability of HCC, mainly ways to increase the future liver remnants in patients through hypertrophy. They include portal vein embolization, sequential transarterial chemoembolization and portal vein embolization, staged hepatectomy, two-staged hepatectomy with portal vein ligation, and Associating Liver Partition and Portal Vein Ligation in Staged Hepatectomy. Herein we review, describe and evaluate these different ways, ways that can be life-saving.

Management of recurrent hepatocellular carcinoma after liver transplant.

Hepatocellular carcinoma (HCC) is the leading cause of deaths in patients with hepatitis B or C, and its incidence has increased considerably over the past decade and is still on the rise. Liver transplantation (LT) provides the best chance of cure for patients with HCC and liver cirrhosis. With the implementation of the MELD exception system for patients with HCC waitlisted for LT, the number of recipients of LT is increasing, so is the number of patients who have recurrence of HCC after LT. Treatments for intrahepatic recurrence after transplantation and after other kinds of surgery are more or less the same, but long-term cure of posttransplant recurrence is rarely seen as it is a "systemic" disease. Nonetheless, surgical resection has been shown to be effective in prolonging patient survival despite the technical difficulty in resecting graft livers. Besides surgical resection, different kinds of treatment are also in use, including transarterial chemoembolization, radiofrequency ablation, high-intensity focused ultrasound ablation, and stereotactic body radiation therapy. Targeted therapy and modulation of immunosuppressants are also adopted to treat the deadly disease.

Samaritan donor interchange in living donor liver transplantation.

BACKGROUND: In order to overcome ABO blood group incompatibility, paired donor interchange has been practised in living donor liver transplantation. Liver transplantations using grafts donated by Samaritan living donors have been performed in Europe, North America, South Korea, and Hong Kong. Such practice is clearly on strong biological grounds although social and psychological implications could be far-reaching. Local experience has been satisfactory but is still limited. As few centers have this arrangement, its safety and viability are still being assessed under a clinical trial setting. METHODS: Here we report a donor interchange involving an ABO-compatible pair with a universal donor and an ABO-incompatible pair with a universal recipient. This matching was not only a variation but also an extension of the donor interchange scheme. RESULTS: The four operations (two donor hepatectomies and two recipient operations) were successful. All the two donors and the two recipients recovered well. Such donor interchange further supports the altruistic principle of organ donation in contrast to exchange for a gain. CONCLUSIONS: Samaritan donor interchange certainly taxes further the ethical challenge of donor interchange. Although this practice has obvious biological advantages, such advantages have to be weighed against the potential increase in potential psychological risks to the subjects in the interchange. Further ethical and clinical evaluations of local and overseas experiences of donor interchange should guide future clinical practice in utilizing this potential organ source for transplantation.

Survival outcomes of right-lobe living donor liver transplantation for patients with high Model for End-stage Liver Disease scores.

BACKGROUND: Controversy exists over whether living donor liver transplantation (LDLT) should be offered to patients with high Model for End-stage Liver Disease (MELD) scores. This study tried to determine whether a high MELD score would result in inferior outcomes of right-lobe LDLT. METHODS: Among 411 consecutive patients who received right-lobe LDLT at our center, 143 were included in this study. The patients were divided into two groups according to their MELD scores: a high-score group (MELD score ≥25; n=75) and a low-score group (MELD score <25; n=68). Their demographic data and perioperative conditions were compared. Univariable and multivariable analyses were performed to identify risk factors affecting patient survival. RESULTS: In the high-score group, more patients required preoperative intensive care unit admission (49.3% vs 2.9%; P<0.001), mechanical ventilation (21.3% vs 0%; P<0.001), or hemodialysis (13.3% vs 0%; P=0.005); the waiting time before LDLT was shorter (4 vs 66 days; P<0.001); more blood was transfused during operation (7 vs 2 units; P<0.001); patients stayed longer in the intensive care unit (6 vs 3 days; P<0.001) and hospital (21 vs 15 days; P=0.015) after transplantation; more patients developed early postoperative complications (69.3% vs 50.0%; P=0.018); and values of postoperative peak blood parameters were higher. However, the two groups had comparable hospital mortality. Graft survival and patient overall survival at one year (94.7% vs 95.6%; 95.9% vs 96.9%), three years (91.9% vs 92.6%; 93.2% vs 95.3%), and five years (90.2% vs 90.2%; 93.2% vs 95.3%) were also similar between the groups. CONCLUSIONS: Although the high-score group had significantly more early postoperative complications, the two groups had comparable hospital mortality and similar satisfactory rates of graft survival and patient overall survival. Therefore, a high MELD score should not be a contraindication to right-lobe LDLT if donor risk and recipient benefit are taken into full account.