Prophylactic liver transplantation for high-risk recurrent hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death in the world. Radical treatment of HCC in early stages results in a long disease-free period and improved overall survival. The choice of optimal management strategy for HCC mainly depends on the severity of the underlying liver disease. For patients with decompensated liver cirrhosis and HCC within Milan criteria (MC), liver transplant (LT) is the choice of treatment. However, for patients with good residual liver reserve and HCC within MC, selection of other curative treatments such as liver resection (LR) or radiofrequency ablation may be a reasonable alternative. For patients without cirrhosis, LR can result in an overall survival similar to that provided by LT. Therefore, it is an accepted alternative to LT especially in areas with organ shortage. However, the cumulative 5-year recurrence rate of HCC post LR might be as high as 70%. For initial transplant-eligible (within MC) patients with recurrent HCC post LR, salvage liver transplant (SLT) was first proposed in 2000. However, most patients with recurrent HCC considered for SLT are untransplantable cases due to HCC recurrence beyond MC or comorbidity. Thus, the strategy of opting for SLT results in the loss of the opportunity of LT for these patients. Some authors proposed the concept of “de principe liver transplant” (i.e., prophylactic LT before HCC recurrence) to prevent losing the chance of LT for these potential candidates. Factors associated with the failure of SLT will be dissected and discussed in three parts: Patient, tumor, and underlying liver disease. Regarding patient-related factors, the rate of transplantability depends on patient compliance. Patients without regular follow-up tend to develop HCC recurrence beyond MC at the time of tumor detection. Advancing age is another factor related to severe comorbidities when LT is considered for HCC recurrence, and these elderly candidates become ineligible as time goes by. Regarding tumor-related factors, histopathological features of the resected specimen are used mostly for determining the prognosis of early HCC recurrences. Such prognostic factors include the presence of microvascular invasion, poor tumor differentiation, the presence of microsatellites, the presence of multiple tumors, and the presence of the gene-expressing signature associated with aggressive HCC. These prognostic factors might be used as a selection tool for SLT or prophylactic LT, while remaining mindful of the fact that most of them are also prognostic factors for post-transplant HCC recurrence. Regarding underlying liver disease-related factors, progression of chronic viral hepatitis and high viral load may contribute to the development of late (de novo) HCC recurrence as a consequence of sustained inflammatory reaction. However, correlation between the severity of liver fibrosis and tumor recurrence is still controversial. Some prognostic scoring systems that integrate these three factors have been proposed to predict recurrence patterns after LR for HCC. Theoretically, after excluding patients with high risk of post-transplant HCC recurrence, either by observation of a cancer-free period or by measurement of biological factors (such as alpha fetoprotein), prophylactic LT following curative resection of HCC could be considered for selected patients with high risk of recurrence to provide longer survival.

Management of early hepatic artery occlusion after liver transplantation with failed rescue

Hepatic artery thrombosis is a serious complication after liver transplantation which often results in biliary complications, early graft loss, and patient death. It is generally thought that early hepatic artery thrombosis without urgent re-vascularization or retransplantation almost always leads to mortality, especially if the hepatic artery thrombosis occurs within a few days after transplantation. This series presents 3 cases of early hepatic artery thrombosis after living donor liver transplantation, in which surgical or endovascular attempts at arterial re-vascularization failed. Unexpectedly, these 3 patients survived with acceptable graft function after 32 mo, 11 mo, and 4 mo follow-up, respectively. The literatures on factors affecting this devastating complication were reviewed from an anatomical perspective. The collective evidence from survivors indicated that modified nonsurgical management after liver transplantation with failed revascularization may be sufficient to prevent mortality from early hepatic artery occlusion. Re-transplantation may be reserved for selected patients with unrecovered graft function.

Reappraisal of surgical decision-making in patients with splenic sclerosing angiomatoid nodular transformation:Case series and literature review

BACKGROUND Many clinicians and surgeons are unfamiliar with the sclerosing angiomatoid nodular transformation(SANT),which is gaining recognition as a benign splenic tumor.We challenge that SANT is rare and whether surgical intervention could be avoided through critical imaging review.AIM To evaluate the incidence of SANT among splenic tumors and the decisionmaking process of SANT management.METHODS Twenty hospitalized patients who underwent splenectomy in 2018 and 2019 in a tertiary university hospital were retrospectively reviewed,and their data on imaging,diagnosis,surgical indications,and courses were recorded.All pathology results were confirmed by pathologist.Discriminative features differentiating SANT from other non-SANT splenic tumors were descriptively analyzed in this case series.RESULTS Fourteen out of 20 patients who underwent splenectomy had splenic tumors,including 3 SANTs(21%splenic tumors),6 non-SANT benign lesions(43%),2 metastatic tumors,and 3 lymphomas.Hypointensity on T2-weighted magnetic resonance imaging(MRI),spoke wheel enhancing pattern in contrasted computed tomography or MRI,and cold spot(low fluorodeoxyglucose uptake)in positron emission tomography(PET)scan helped establish the diagnosis of SANT.Lymphoma,presenting with a hot spot on the PET scan were differentiated from SANT.Surgical indications were reformatted for splenic tumors.Splenectomy need not be performed in patients with typical imaging features of SANT.CONCLUSION SANT is not a rare disease entity in clinical practice.Splenectomy should not be routinely indicated as the only management option for SANT with typical imaging features.

Appendicitis-mimicking presentation in fishbone induced microperforation of the distal duodenum:A case report

BACKGROUND Upper gastrointestinal fishbone microperforations are rare and not commonly reported in medical literature.Despite the increasing use of computer tomography(CT)imaging and the employment of the Alvardo criteria,misdiagnosis of acute appendicitis can still occur.We report the rare case of an elderly Chinese gentleman who had a fish-bone induced microperforation of the duodenum that closely mimicked the symptoms of acute appendicitis.CASE SUMMARY This 79-year-old man presented with migratory lower abdominal pain that localized at his periumbilical region and right lower quadrant.He had associated pyrexia,general malaise and was noted to have an elevated white cell count.CT investigations initially revealed a distended appendix which was resected laparoscopically but showed no obvious signs of gross inflammation.The patient then deteriorated clinically and had increased oxygen requirements immediately after the surgery.This prompted further investigations.A further review of his CT scan revealed a fine fishbone microperforation in the distal duodenum associated with retroperitoneal abscess formation and seepage extending into the right lower quadrant.He was then started on broad spectrum intravenous antibiotics and subsequently underwent a laparotomy 12 h later to manage the obscure aetiology and to drain the abscess.The post-operative course was uneventful and he was discharged 11 d later including a 2-d stay in the intensive care unit.CONCLUSION This case offers an insight into a potential mimic of acute appendicitis and the diagnostic difficulties experienced in such presentations.

Perspective of antiviral therapeutics for hepatitis C after liver transplantation

Hepatitis C virus(HCV) almost recurs after liver transplantation for HCV-related liver cirrhosis or hepatocellular carcinoma. Management of HCV recurrence after liver transplantation is challenging because the traditional interferon-based therapy is often patient-intolerable and inducing cytopenia, and dose reduction is needed. The response rate in liver recipients is inferior to those of chronic HCV infection. About 5 percent of liver recipients receiving interferon-based therapy would develop immune-mediated graft injury and may need retransplantation. Recent advances of anti-HCV therapy for chronic HCV infection has evolutionary changing the schema from interferon-based, to interferon-free, and even to ribavirin-free, all oral combinations for pan-genotypes. Management of HCV recurrence after liver transplantation is currently evolving too and promising results will soon come to the stage. This "fast-track" concise review focuses on the issues relevant to HCV recurrence after liver transplantation and provides up-to-date information of the trend of the management. A real-world case demonstration of management was presented here to illustrate the potential complications of anti-HCV therapy after liver transplantation.