Predictors of the outcomes of acute-on-chronic hepatitis B liver failure

AIM:To identify the risk factors in predicting the outcome of acute-on-chronic hepatitis B liver failure patients.METHODS:We retrospectively divided 113 patients with acute-on-chronic liver failure-hepatitis B virus(ACLF-HBV) and without concurrent hepatitis C or D virus infection and hepatocellular carcinoma into two groups according to their outcomes after anti-HBV therapy.Their demographic,clinical,and biochemical data on the day of diagnosis and after the first week of treatment were analyzed using the Mann-Whitney U test,Fisher's exact test,and a multiple logistic regression analysis.RESULTS:The study included 113 patients(87 men and 26 women) with a mean age of 49.84 years.Fiftytwo patients survived,and 61 patients died.Liver failure(85.2%),sepsis(34.4%),and multiple organ failure(39.3%) were the main causes of death.Multivariate analyses showed that Acute Physiology and Chronic Health Evaluation(APACHE) Ⅱ scores ≥ 12 [odds ratio(OR) = 7.160,95% CI:2.834-18.092,P < 0.001] and positive blood culture(OR = 13.520,95% CI:2.740-66.721,P = 0.001) on the day of diagnosis and model for end-stage liver disease(MELD) scores ≥ 28(OR = 8.182,95% CI:1.884-35.527,P = 0.005) after the first week of treatment were independent predictors of mortality.CONCLUSION:APACHE Ⅱ scores on the day of diagnosis and MELD scores after the first week of anti-HBV therapy are feasible predictors of outcome in ACLFHBV patients.

Roux-en-Y reconstruction does not require gastric decompression after radical distal gastrectomy

AIM: To determine whether routine nasogastric (NG) decompression benefitted patients undergoing radical gastric surgery. METHODS: Between January 1998 and December 2008, 519 patients who underwent distal gastrectomy for gastric cancer were retrospectively divided into 2 time-period cohorts; those treated with Billroth Ⅱ (BⅡ) reconstruction in the first 6 years and those with Roux-en-Y (RY) reconstruction in the last 5 years. In the latter group, the patients were further divided into 2 subgroups; with and without nasogastric decompression.RESULTS: Postoperatively, there were no significant differences in the number of anastomotic leaks between the 3 groups. In the tubeless RY group, time to semiliquid diet was significantly shorter than in the other 2 groups (4.4 d ± 1.4 d vs 7.2 d ± 1.3 d and 5.9 d ± 1.2 d, P = 0.005). The length of postoperative stay was significantly increased in patients with BⅡ reconstruction compared with patients with RY reconstruction with/without NG decompression (15.4 d ± 4.3 d in BⅡ group vs 12.6 d ± 3.1 d in decompressed RY and 11.4 d ± 3.4 d in the tubeless RY group, P = 0.035). The postoperative pneumonia rate was lowest in the tubeless group and highest in the BⅡ group (1.4% vs 4.6%, P = 0.01). Severe sore throat was noted in 59 (20.7%) members of the BⅡ group, 18 (17.4%) members of the decompressed RY group and 6 (4.2%) members of the tubeless RY group. Fewer patients in the tubeless group complained of severe sore throat (P = 0.001). CONCLUSION: This study provides support for abandoning routine NG decompression in patients undergoing subtotal gastrectomy with Roux-en-Y gastrojejunostomy.

Mechanisms inactivating the gene for E-cadherin in sporadic gastric carcinomas

瞄准：为了学习 CDH1/E-cadherin (电子恶棍) 的角色，基因改变介绍在胃的癌(GC ) 在激活在 CDH1 的机制包括变化，杂合现象(LOH ) 的损失，倡导者多型性和 hypermethylation。方法：标本与 GC 从 70 个病人通过手术被收集。Allelotyping PCR 和定序的 LOH，使中毒的高压力液相色谱法和 DNA 的察觉，限制碎片长度多型性分析，甲基化 specific PCR，和免疫组织化学的染色被使用。结果：倡导者多型性不是在激活的电子恶棍的主要机制。仅仅一截断变化在一个弥漫的类型肿瘤(3%) 被发现。LOH 和倡导者 hypermethylation 是在激活的电子恶棍的主要机制，但是有趣地，在 CDH1 的肿瘤和 hypermethylation 在突变而产生之遗传的损失(LOH ) 的部分之间有一个否定协会。因此 LOH 和 hypermethylation 是涉及 GC 的二条不同致瘤的小径。结论：给体细胞突变是极其低的，在 LOH 和 hypermethylation 之间的关系是反的调查结果，这三个因素的任何二联合不能在激活完成 CDH1 的古典二点击的假设。因此，在 transcriptional 水平或在 translational 以后水平操作的另外的机制可能被要求在激活导致 E-cadherin。

Hepatic hemodynamic changes during liver transplantation: A review

Liver transplantation is performed in the recent decades with great improvements not only technically but also conceptually. However, there is still lack of consensus about the optimal hemodynamic characteristics during liver transplantation. The representative hemodynamic parameters include portal vein pressure, portal vein flow, and hepatic venous pressure gradient; however, there are still others potential valuable parameters, such as total liver inflow and hepatic artery flow. All the parameters are correlated closely and some internal modulating mechanisms, like hepatic arterial buffer response, occur to maintain stable hepatic inflow. To distinguish the unique importance of each hepatic and systemic parameter in different states during liver transplantation, we reviewed the published data and also conducted two transplant cases with different surgical strategies applied to achieve ideal portal inflow and pressure.

Helicobacter pylori infection in relation to E-cadherin gene promoter polymorphism and hypermethylation in sporadic gastric carcinomas

AIM: To study Helicobacter pylori (H pylori) infection in relation to E-cadherin (E-cad) promoter polymorphism and hypermethylation in GCs.METHODS: Specimens were taken from representative cancerous lesions and adjacent non-cancerous epithelia of 67 resected GCs. Hpyloriwas detected by real-time PCR of the cagA gene from non-neoplastic epithelium.E-cad promoter polymorphism and hypermethylation were determined by restriction fragment length polymorphism analysis and methylation-specific PCR, respectively. Expression of E-cad protein was determined by immunohistochemistry.RESULTS: Hpyloriwas found in 57% of patients with GC.H pylori infection was more frequently found in tumors with the -160C/C genotype than those with the -160C/A and -160A/A genotypes (74% vs47%, P = 0.02). Hpylori infection was associated with E-cad methylation in nonneoplastic epithelium; however, no significant difference in H pylori was observed between methylated and unmethylated cancerous lesions.CONCLUSION: Patients with the -160C/C genotype might require Hpyloriinfection to promote the inactivation of CDH1, suggesting that Hpylori infection might affect GC in an initial stage because polymorphism is germ line.Mechanism of hypermethylation of CDH1 promoter in GC is complex, and Hpyloriinfection might affect it in an initial stage.

Comprehensive risk assessment for early neurologic complications after liver transplantation

AIM: To determine risk factors for early neurologic complications(NCs) after liver transplantation from perspective of recipient, donor, and surgeon. METHODS: In all, 295 adult recipients were enrolled consecutively between August 2001 and February 2014 from a single medical center in Taiwan. Any NC in the first 30 d post-liver transplantation, and perioperative variables from multiple perspectives were collected and analyzed. The main outcome was a 30-d NC. Generalized additive models were used to detect the non-linear effect of continuous variables on outcome, and to determine cut-off values for categorizing risk. Risk factors were identified using multiple logistic regression analysis. RESULTS: In all, 288 recipients were included, of whom 142(49.3%) experienced at least one NC, with encephalopathy being the most common 106(73%). NCs prolonged hospital stay(35.15 ± 43.80 d vs 20.88 ± 13.58 d, P < 0.001). Liver recipients' age < 29 or ≥ 60 years, body mass index < 21.6 or >27.6 kg/m^2, Child-Pugh class C, history of preoperative hepatoencephalopathy or mental disorders, day 7 tacrolimus level > 8.9 ng/m L, and postoperative intraabdominal infection were more likely associated with NCs. Novel risk factors for NCs were donor age < 22 or ≥ 40 years, male-to-male gender matching, graftrecipient weight ratio 0.9%-1.9%, and sequence of transplantation between 31 and 174. CONCLUSION: NCs post- liver transplantation occurs because of factors related to recipient, donor, and surgeon. Our results provide a basis of risk stratification for surgeon to minimize neurotoxic factors during transplantation.

Sclerosing encapsulating peritonitis in a liver transplant patient: A case report

We report a patient with HBV-related hepatocellular carcinoma (HCC) and refractory ascites who had received a peritoneal-venous shunt (PVS) 1 year before liver transplantation. Urgent surgical intervention following bowel obstruction and failure of immunosuppression therapy. No intestinal obstruction was found during an initial PVS. However, intestinal obstruction developed 2 wk after liver transplantation; and a cocoon abdomen was found upon exploration. This is the first reported case of cocoon abdomen caused by PVS and exacerbated by liver transplantation.

Ruptured hepatoblastoma with massive internal bleeding in an adult

Hepatoblastoma is the most common primary hepatic tumor of children. However, only a very few cases have been reported in adults. Most studies support treatment with chemotherapy followed by surgical resection. We present the first reported case of adult hepatoblastoma in Taiwan. A 52-year-old female suffered from sudden onset of abdominal pain and general weakness for days.Internal bleeding with hemorrhagic shock was suspected and two massive lesions in both lobes of the liver with hemoperitoneum were noted from imaging studies.Surgical resection of the larger left lobe tumor and radio-frequency ablation of the right smaller one were performed. The histopathology diagnosis was of a hepatoblastoma.

Methylation of IRAK3 is a novel prognostic marker in hepatocellular carcinoma

AIM: To examine the methylation levels of interleukin-1 receptor-associated kinase 3(IRAK3) and GLOXD1 and their potential clinical applications in hepatocellular carcinoma(HCC).METHODS: m RNA expression and promoter methylation of IRAK3 and GLOXD1 in HCC cells were analyzed by reverse transcription-polymerase chain reaction(RTPCR) and methylation-specific PCR(MSP), respectively. Using pyrosequencing results, we further established a quantitative MSP(Q-MSP) system for the evaluation of IRAK3 and GLOXD1 methylation in 29 normal controls and 160 paired HCC tissues and their adjacent nontumor tissues. We also calculated Kaplan-Meier survival curves to determine the applications of gene methylation in the prognosis of HCC.RESULTS: IRAK3 and GLOXD1 expression was partially restored in several HCC cell lines after treatment with 5-aza-2′-deoxycytidine(DNA methyltransferase inhibitor; 5DAC). A partial decrease in the methylated band was also observed in the HCC cell lines after 5DAC treatment. Using GLOXD1 as an example, we found a significant correlation between the data obtained from the methylation array and from pyrosequencing. The methylation frequency of IRAK3 and GLOXD1 in HCC tissues was 46.9% and 63.8%, respectively. Methylation of IRAK3 was statistically associated with tumor stage. Moreover, HCC patients with IRAK3 methylation had a trend toward poor 3-year disease-free survival(P < 0.05). CONCLUSION: IRAK3 and GLOXD1 were frequently methylated in HCC tissues compared to normal controls and nontumor tissues. IRAK3 methylation was associated with tumor stage and poor prognosis of patients. These data suggest that IRAK3 methylation is a novel prognostic marker in HCC.

Liver transplantation with simultaneous splenectomy increases risk of cancer development and mortality in hepatocellular carcinoma patients

BACKGROUND Splenectomy has previously been found to increase the risk of cancer development,including lung,non-melanoma skin cancer,leukemia,lymphoma,Hodgkin’s lymphoma,and ovarian cancer.The risk of cancer development in liver transplantation(LT)with simultaneous splenectomy remains unclear.AIM To compare hepatocellular carcinoma(HCC)recurrence and de novo malignancy between patients undergoing LT with and without simultaneous splenectomy.METHODS We retrospectively analyzed the outcomes of 120 patients with HCC within the University of California San Francisco criteria who received LT with(n=35)and without(n=85)simultaneous splenectomy in the Tri-Service General Hospital.Univariate and multivariate Cox regression analyses for cancer-free survival and mortality were established.The comparison of the group survival status and group cancer-free status was done by generating Kaplan–Meier survival curves and log-rank tests.RESULTS The splenectomy group had more hepatitis C virus infection,lower platelet count,higher-fetoprotein level,and longer operating time.Splenectomy and age were both positive independent factors for prediction of cancer development[hazard ratio(HR):2.560 and 1.057,respectively,P<0.05].Splenectomy and hypertension were positive independent factors for prediction of mortality.(HR:2.791 and 2.813 respectively,P<0.05).The splenectomy group had a significantly worse cancer-free survival(CFS)and overall survival(OS)curve compared to the non-splenectomy group(5-year CFS rates:53.4%vs 76.5%,P=0.003;5-year OS rate:68.1 vs 89.3,P=0.002).CONCLUSION Our study suggests that simultaneous splenectomy should be avoided as much as possible in HCC patients who have undergone LT.

Intrauterine contraceptive device appendicitis: A case report

Uterine perforation is one of the serious complications associated with use of the intrauterine contraceptive device (IUD). Uterine perforation by IUD can involve several neighboring organs. A case of acute appendicitis was caused by a Multiload Cu 375 IUD inserted previously.This is a rare complication and only fourteen previous cases were recorded in the literature.