Life made easy:simplifying reconstruction for dual portal veins in adult right lobe live donor liver transplantation

In live donor liver transplantation, anatomical anomalies of the portal vein are more frequently encountered in right lobe than left lobe grafts. Of these, a dual portal vein is one of the most common anatomical anomalies encountered. We hereby report our method of using a recipient portal vein patch after venoplasty for reconstruction in a right lobe graft with separate anterior and posterior portal vein branches.

Role of C11-FDG dual-tracer PET-CT scan in metastatic screening of hepatocellular carcinoma-a cost-effectiveness analysis

Background:We aimed to identify predictive factors for positron emission tomography(PET)-detected hepatocellular carcinoma(HCC)metastasis and a cost-effective approach to preoperative PET-computed tomography(CT)for detecting metastasis.Methods:Clinicopathological and survival data of HCC patients having PET-CT with 18F-fludeoxyglucose(FDG)and 11C-acetate(ACT)following contrast-enhanced CT/magnetic resonance imaging(MRI)for preoperative tumor staging were reviewed.Binary logistic regression was performed to identify predictive factors for PET-detected metastasis.A cost-benefit analysis model was built for the incurred costs and the impact of PET-CT findings on treatment strategy was studied.Results:Totally 152 patients were analyzed.Dual-tracer PET-CT detected metastasis in 17 patients(11%).By multivariate analysis,alpha-fetoprotein(AFP)≥400 ng/mL[relative risk(RR):4.30,95%confidence interval(CI):1.41-13.15,P=0.011]and bilobar disease(RR:3.94,95%CI:1.24-12.52,P=0.014)were independent predictive factors for PET-detected metastasis.PET-CT findings altered the treatment strategy for 12 patients(7.9%);three partial hepatectomies,eight episodes of transarterial chemoembolization(TACE)and one episode of ablation were avoided,with an estimated cost-saving of US$91,000,$150,000 and$10,600 respectively.Had the PET-CT been performed only for patients with AFP≥400 ng/mL or bilobar disease(n=74),metastasis would have been confirmed in 14 patients(18.9%),and the cost-saving per patient was estimated at US$1,070.Conclusions:Dual-tracer PET-CT is cost-effective and useful for preoperative HCC staging in patients with AFP≥400 ng/mL or bilobar disease.Its routine use in preoperative workup for all HCC patients is not recommended.Unilobar disease with AFP<400 ng/mL can achieve good negative predictive value for PET-detected metastasis.Screening patients with either factor can avoid unnecessary procedures and is thus cost-effective for preoperative HCC workup.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)—pushing the envelope in modulation of future liver remnant before major hepatectomy

Insufficient future liver remnant (FLR) is an important factor that precludes patient from upfront major liver resection as it predisposes to post-hepatectomy liver failure and mortality. As such, augmentation of FLR by portal vein embolization (PVE) was the conventional approach to improve the safety profile of major hepatectomy. In recent years, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been popularized as an alternative approach for FLR augmentation (1,2). However, the initial inception of the ALPPS procedure was met by criticism for its high incidence of procedure-related morbidity, such as bile leakage and sepsis (3). In light of this issue, an international registry was set up for collection of cases and experience around the world and soon after that, the first International Expert Meeting was held in Hamburg in 2015 that led to the publication of eight recommendations on terminology of the procedures, indications and techniques for ALPPS (4). Two years later, a pre-congress meeting was held during the EHPBA (European Hepatopancreatobiliary Association) 12th Annual Congress in Mainz, Germany to celebrate the 10th Anniversary of ALPPS (5) since the first case was performed by Prof. Hans Schlitt a decade ago (1). During this meeting, ten different aspects on ALPPS were covered including surgical anatomy, underlying mechanisms, perioperative assessment of liver function, technical approach, indications and its effectiveness in comparison to two-stage hepatectomy.