Liver transplantation for combined hepatocellular carcinoma and cholangiocarcinoma:A multicenter study

BACKGROUND Patients with combined hepatocellular carcinoma and cholangiocarcinoma(cHCC-CC)are not traditionally considered eligible for liver transplantation(LT)AIM To compare outcomes between living donor LT(LDLT)patients with hepatocellular carcinoma(HCC)and LT patients with cHCC-CC and to identify risk factors for tumor recurrence and death after LT in cHCC-CC patients.METHODS Data for pathologically diagnosed cHCC-CC patients(n=111)who underwent LT from 2000 to 2018 were collected for a nine-center retrospective review.Patients(n=141)who received LDLT for HCC at Samsung Medical Center from January 2013 to March 2017 were selected as the control group.Seventy patients in two groups,respectively,were selected by 1:1 matching.RESULTS Cumulative disease-free survival(DFS)and overall survival(OS)in the cHCC-CC group were significantly worse than in the HCC group both before and after matching.Extrahepatic recurrence incidence in the cHCC-CC group was higher than that in the HCC group(75.5%vs 33.3%,P<0.001).Multivariate analysis demonstrated that the cHCC-CC group had significantly higher rates of tumor recurrence and death compared to the HCC group.In cHCC-CC subgroup analysis,frequency of locoregional therapies>3,tumor size>3 cm,and lymph node metastasis were predisposing factors for tumor recurrence in multivariate analysis.Only a maximum tumor size>3 cm was a predisposing factor for death.CONCLUSION The poor prognosis of patients diagnosed with cHCC-CC after LT can be predicted based on the explanted liver.Frequent regular surveillance for cHCC-CC patients should be required for early detection of tumor recurrence.

Biliary phytobezoar resulting in intestinal obstruction

Phytobezoar is the most common type of bezoar.It is composed of indigestible vegetable matter and is usually found in the stomach.Biliary phytobezoar is extremely rare and difficult to diagnose preoperatively.The pathogenesis is not clear,and there have been only a few reports of biliary bezoars associated with sphincteric impairmentat the ampulla of Vater.Here,we present a report of biliary bezoar that resulted in jejunal obstruction.We were unable to identifythe bezoar in the extrahepatic bile duct until it obstructed the small bowel lumen.To our knowledge,this is the first report of small bowel obstruction resulting frommigration of a biliary bezoar.

Thermodynamics of Ti in liquid steels and slags

Thermodynamics of Ti in liquid steels and slags was studied in order to establish a data base for the prediction of TiO_x and TiN formation in liquid steels.The interaction parameters between Ti and i(i = Cr,Ti,Al, Si,Ni,Mo,Nb,N,O) in liquid iron and the equilibrium constants for the formation of TiN and TiO_x in liquid iron were determined as a function of temperature.In view of high Ti yield during ladle treatment,thermodynamics of titanium oxides in ladle slags was studied as well.Activity coefficient and redox equilibrium of TiO_x in MgO saturated CaO-Al_2O_3 slag are also discussed by measuring the distribution ratio of Ti between slag and iron melts and the Ti^(3+)/Ti^(4+) ratio in slag at 1 873 K.

Clinical significance of surgical resection for hepatocellular carcinoma with portal vein invasion:a nationwide cohort study

Background:Hepatocellular carcinoma(HCC)with portal vein invasion(PVI)is considered an advanced stage with a poor prognosis.Although current guidelines recommend systemic treatment for HCC with PVI,surgical resection could produce acceptable outcomes in selected patients.This study aimed to identify the clinical significance of surgical resection for HCC with PVI patients using a large-scale nationwide registry.Methods:This retrospective,multicenter,observational cohort analyzed data from the Korean Primary Liver Cancer Registry.A total of 16,781 patients who were newly diagnosed with HCC between 2008 and 2018 were enrolled in this study.Patients with worse Child-Turcotte-Pugh scores(≥7)or performance status(≥2)were excluded.Among them,998 patients who received treatment for HCC with PVI were included in the analysis and were divided into two groups:resection group of 151(15.1%)and palliative group of 847(84.9%)who received transarterial and systemic therapy according to the treatment intent.After matching the number and size of the tumors and model for end-stage liver disease(MELD)score between the groups,the final study cohort for analysis comprised 151(26.6%)patients in the resection group and 417(73.4%)in the palliative group.The primary endpoints were overall survival(OS)and cancer-specific survival(CSS).Results:The number and maximum size of HCC did not differ between the resection and palliative groups after matching[1(range,1-5)vs.1(range,1-6),P=0.11 and 5.5(range,1.2-20.6)vs.6.0(range,1.0-20.5)cm,P=0.24,respectively].Tumor markers,including alpha-fetoprotein(AFP)and protein induced by vitamin K absence or antagonist-II(PIVKA-II),also did not differ between the groups(P=0.29 and P=0.36,respectively).The 5-year OS and CSS rates of the resection and palliative groups were 44.8%and 17.4%(P<0.001)and 47.7%and 18.6%(P<0.001),respectively.Multivariate analysis showed that palliative treatment intent was the most significant risk factor for OS and CSS[odds ratio(OR)=2.24;95%confidence interval(CI):1.66-3.02;P<0.001 and OR=2.29;95%CI:1.68-3.12;P<0.001,respectively].Conclusions:Surgical resection could significantly improve OS and CSS in selected HCC with PVI patients who have preserved liver function and performance status.

Clinical feasibility of modified extended left hemihepatectomy in advanced perihilar cholangiocarcinoma

Curative resection is undoubtedly the most important prognostic factor in perihilar cholangiocarcinoma(1).The current consensus of surgical resection of perihilar cholangiocarcinoma consists of hemihepatectomy,including caudate lobectomy and aggressive lymphadenectomy,depending on the extent of bile duct invasion.Critical decisions on whether to resect the right or left liver and whether to perform an extended hepatectomy or trisectionectomy are all aimed at obtaining negative radial and longitudinal margins(2,3).

New-onset diabetes after adult liver transplantation in the Korean Organ Transplantation Registry (KOTRY) study

Background:New-onset diabetes after transplantation(NODAT)is a serious complication following liver transplantation(LT).The present study aimed to investigate the incidence of and risk factors for NODAT using the Korean Organ Transplantation Registry(KOTRY)database.Methods:Patients with history of pediatric transplantation(age≤18 years),re-transplantation,multi-organ transplantation,or pre-existing diabetes mellitus were excluded.A total of 1,919 non-diabetic adult patients who underwent a primary LT between May 2014 and December 2017 were included.Risk factors were identified using Cox regression analysis.Results:NODAT occurred in 19.7%(n=377)of adult liver transplant recipients.Multivariate analysis showed steroid use,increased age,and high body mass index(BMI)in recipients,and implantation of a left-side liver graft was closely associated with NODAT in adult LT.In living donor liver transplant(LDLT)patients(n=1,473),open donor hepatectomy in the living donors,steroid use,small for size liver graft(graft to recipient weight ratio≤0.8),increased age,and high BMI in the recipient were predictive factors for NODAT.The use of antimetabolite and basiliximab induction reduced the incidence of NODAT in adult LT and in adult LDLT.Conclusions:Basiliximab induction,early steroid withdrawal,and antimetabolite therapy may prevent NODAT after adult LT.High BMI or advanced age in liver recipients,open donor hepatectomy in living donors,and small size liver graft can predict the occurrence of NODAT after adult LT or LDLT.

The beneficial impacts of splanchnic vasoactive agents on hepatic functional recovery in massive hepatectomy porcine model

Background:Excessive portal pressure after massive hepatectomy can cause hepatic sinusoidal injury and have deleterious impacts on hepatic functional recovery,contributing to developing post-hepatectomy liver failure.This study aimed to assess the effects of splanchnic vasoactive agents on hepatic functional recovery and regeneration while clarifying the underlying mechanism,using a 70%hepatectomy porcine model.Methods:Eighteen pigs undergoing 70%hepatectomy were involved in this study and divided into three groups:control(n=6),terlipressin(n=6),and octreotide(n=6).Terlipressin(0.5 mg)and octreotide(0.2 mg)were administered 3 times a day for each group with the first dose starting just before surgery until the 7th postoperative day,at which time the surviving pigs were sacrificed.During the period,portal pressure,liver weight,biochemical analysis,histological injury score,and molecular markers were evaluated and compared between groups.Results:The 7-day survival rates in the octreotide,terlipressin,and control groups were 100%,83.3%,and 66.7%,respectively.The portal pressures decreased in both terlipressin and octreotide groups than the control group at 30 minutes,1 hour and 6 hours after hepatectomy.The amount of regeneration measured by liver weight to body weight ratio at the time of sacrifice in the terlipressin group was smaller than that in the control group(117%vs.129%,P=0.03).Serum aspartate aminotransferase(AST)and total bilirubin levels at 1 and 6 hours after hepatectomy and prothrombin time/international normalized ratio(PT/INR)at 6 hours after hepatectomy were significantly improved in the terlipressin and octreotide groups compared to the control group.Serum endothelin-1(ET-1)was significantly lower in the terlipressin group than that in the control group 6 hours after hepatectomy(P<0.01).The histological injury score in the control group was significantly higher than that in the terlipressin group on the 7th postoperative day(P<0.01).Conclusions:Splanchnic vasoactive agents,such as terlipressin and octreotide,could effectively decrease portal pressure and attenuate liver injury after massive hepatectomy.