Pyogenic liver abscess secondary to gastric perforation of an ingested toothpick:A case report

BACKGROUND Liver abscess due to foreign body-induced gastrointestinal tract perforation is a rare event that could be misdiagnosed due to low suspicion.Less than 100 cases have been reported to date.CASE SUMMARY We report a case of a 53-year old female patient with pyogenic liver abscess secondary to ingestion of a toothpick with penetration through the lesser curvature of the stomach.The patient presented with persistent epigastric pain.Abdominal computed tomography demonstrated the presence of a linear radiopaque object associated with abscess formation in the left liver lobe.Inflammatory changes in the lesser curvature of the stomach indicated gastric wall penetration by the object.As the abscess was refractory to antibiotic treatment,laparoscopic liver resection was performed to remove the foreign body and adjacent liver parenchyma.Following surgery,symptoms fully resolved without any sequelae.CONCLUSION This rare case demonstrates the importance of considering foreign body penetration as a cause of pyogenic liver abscess,particularly in abscesses of unknown origin that are resistant to antibiotic therapy.Clinical suspicion,early diagnosis,and prompt removal of the foreign body could lead to improved outcomes in these patients.

Intra-arterial lipo-prostaglandin E1 infusion for arterial spasm in liver transplantation:A case report

BACKGROUND Hepatic artery obstruction is a critical consideration in graft outcomes after living donor liver transplantation.We report a case of diffuse arterial vasospasm that developed immediately after anastomosis and was managed with an intra-arterial infusion of lipo-prostaglandin E1(PGE1).CASE SUMMARY A 57-year-old male with hepatitis B virus-related liver cirrhosis and hepatocellular carcinoma underwent ABO-incompatible living donor liver transplant.The grafted hepatic artery was first anastomosed to the recipient’s right hepatic artery stump.However,the arterial pulse immediately weakened.Although a new anastomosis was performed using the right gastroepiploic artery,the patient’s arterial pulse rate remained poor.We attempted angiographic intervention immediately after the operation;it showed diffuse arterial vasospasms like‘beads on a string’.We attempted continuous infusion of lipo-PGE1 overnight via an intra-arterial catheter.The next day,arterial flow improved without any spasms or strictures.The patient had no additional arterial complications or related sequelae at the time of writing,1-year post-liver transplantation.CONCLUSION Angiographic evaluation is helpful in cases of repetitive arterial obstruction,and intra-arterial infusion of lipo-PGE1 may be effective in treating diffuse arterial spasms.

Pre-operative factors that can predict neoplastic polypoid lesions of the gallbladder

AIM:To investigate the preoperative factors that can predict neoplastic polypoid lesions of the gallbladder(PLGs) as well as malignant PLGs.METHODS:A retrospective analysis was conducted on the 210 consecutively enrolled patients who underwent cholecystectomy due to a PLG larger than 10 mm,as was determined by preoperative trans-abdominal ultrasonography or endoscopic ultrasonography.We ana-lyzed the medical,laboratory,radiologic data and the pathologic results.RESULTS:In 210 cases,146 had non-neoplastic polyps(69.5%) and 64 cases were neoplastic polyps(30.5%).An older age(≥ 65 years),the presence of diabetes mellitus(DM) and the size of polyp(≥ 15 mm) were revealed to be independent predictive variables for neoplastic polyps with odd ratios(OR) of 2.27(P = 0.044),2.64(P = 0.021) and 4.94(P < 0.01),respectively.Among the neoplastic PLGs,an older age(≥ 65 years),the presence of DM and polyp size(≥ 15 mm) were associated with malignancy with ORs of 4.97(P = 0.005),6.13(P = 0.001) and 20.55(P < 0.001),respectively.CONCLUSION:Among patients with PLGs larger than 10 mm in size,higher risk groups such as elderly patients more than 65 years old,those with DM or a large polyp size(≥ 15 mm) should be managed by cholecystectomy.

Portal vein embolization failure:Current strategies and future perspectives to improve liver hypertrophy before major oncological liver resection

Portal vein embolization(PVE)is currently considered the standard of care to improve the volume of an inadequate future remnant liver(FRL)and decrease the risk of post-hepatectomy liver failure(PHLF).PHLF remains a significant limitation in performing major liver surgery and is the main cause of mortality after resection.The degree of hypertrophy obtained after PVE is variable and depends on multiple factors.Up to 20%of patients fail to undergo the planned surgery because of either an inadequate FRL growth or tumor progression after the PVE procedure(usually 6-8 wk are needed before surgery).The management of PVE failure is still debated,with a lack of consensus regarding the best clinical strategy.Different additional techniques have been proposed,such as sequential transarterial chemoembolization followed by PVE,segment 4 PVE,intra-portal administration of stem cells,dietary supplementation,and hepatic vein embolization.The aim of this review is to summarize the up-to-date strategies to overcome such difficult situations and discuss future perspectives on improving FRL hypertrophy.

Immunotherapy for hepatocellular carcinoma:A promising therapeutic option for advanced disease

Hepatocellular carcinoma(HCC)is the third leading cause of cancer-related deaths worldwide,and its incidence continues to increase.Despite improvements in both medical and surgical therapies,HCC remains associated with poor outcomes due to its high rates of recurrence and mortality.Approximately 50% of patients require systemic therapies that traditionally consist of tyrosine kinase inhibitors.Recently,however,immune checkpoint inhibitors have revolutionized HCC management,providing new therapeutic options.Despite these major advances,the different factors involved in poor clinical responses and molecular pathways leading to resistance following use of these therapies remain unclear.Alternative strategies,such as adoptive T cell transfer,vaccination,and virotherapy,are currently under evaluation.Combinations of immunotherapies with other systemic or local treatments are also being investigated and may be the most promising opportunities for HCC treatment.The aim of this review is to provide updated information on currently available immunotherapies for HCC as well as future perspectives.

Laparoscopic anatomical versus non-anatomical liver resection for hepatocellular carcinoma in the posterosuperior segments:a propensity score matched analysis

Background:Since laparoscopic anatomical resection(LAR)for tumors,especially located in the posterosuperior(PS)segments of the liver remains difficult,laparoscopic non-anatomical resection(LNAR)are generally preferred.To compare the clinical outcomes between LAR and LNAR for hepatocellular carcinoma(HCC)located in the PS segments.Methods:We retrospectively reviewed the data for 1,029 patients who underwent hepatectomy for HCC between 2004 and 2019.Of 167 patients who underwent laparoscopic hepatectomy for HCC in PS segments,64 underwent LNAR and 103 underwent LAR.Patients were matched one-to-one using propensity score matching(46:46).Results:LNAR was associated with significantly shorter operation time(P=0.001),lower estimated blood loss(P=0.001),lower transfusion rate(P=0.006)and shorter hospital stay(P=0.012)than LAR.The respective 1-,3-,and 5-year overall survival rates(LAR:95.3%,87.1%,and 77.8%;LNAR:96.7%,91.6%,and 85.0%;P=0.262)and recurrence-free survival rates(LAR:75.7%,70.3%,and 68.9%;LNAR:81.8%,58.3%,and 55.3%;P=0.879)were similar.The intrahepatic recurrence rate was significantly higher in LNAR group than in LAR group(78.6%vs.57.1%,P=0.023),but the post-recurrence treatments differed significantly between the two groups(P=0.016);the re-resection rate was much greater in the LNAR group(45.0%vs.0%)group.The respective 1-,3-,and 5-year post-recurrence survival rates were similar in the LAR and LNAR groups(P=0.212).After recurrence,survival in re-resection group was significantly greater than not(P=0.026).Conclusions:LNAR is safe and feasible for HCC located in PS segments,and provided acceptable oncologic outcomes that are comparable to those of LAR.LNAR can be considered for patient with tumor located in PS segment when LAR is not feasible.

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.

Comparison of outcomes between laparoscopicvs. open liver resection for intermediate stage hepatocellular carcinoma

Aim: The Barcelona Clinic Liver Score (BCLC) currently limits hepatic resection only for small, solitary tumors measuring 2-3 cm with no signs of portal hypertension (PHT) or macrovascular invasion. The aim of this study was to show the benefit of surgical resection, and to compare the peri-operative and long-term outcomes between laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC) classified as intermediate stage (B) under BCLC. Methods: From 2004 to 2013, 49 patients staged as intermediate (BCLC B) and who underwent hepatic resection was included. These patients were divided into LLR or OLR. Demographics, tumor characteristics, recurrence rates and overall survival (OS) were compared between the 2 groups. Results: Forty-nine patients were included and grouped into LLR (n = 28) and OLR (n = 21). The average tumor number was 2 ± 1 for both groups, while the mean tumor size was 4.4 ± 1.7 cm and 5.3 ± 2.6 cm for the LLR and OLR group, respectively. When compared with OLR, LLR had lower post-operative complications (14.3% vs. 33.3%, P = 0.114), and a statistically significant shorter hospital stay than the OLR group (9 vs. 21 days, P = 0.023). The LLR group also achieved a statistically significant difference in complete R0 resection as compared with the OLR group (P =0.016). The OS and disease-free survival (DFS) at 1, 3 and 5 years were comparable between LLR and OLR (OS: 89.1% vs. 76.2%;70.4% vs. 55.9%;58.6% vs. 43.5%, P = 0.583;DFS: 59.3% vs. 51.0%;20.2% vs. 44.6%;16.2% vs. 37.2%, P = 0.947, respectively). Conclusion: LLR showed comparable outcomes compared to OLR in the treatment of HCC staged BCLC B. Therefore, LLR as well as OLR can be considered in selective patients in the BCLC B group.

The role of minimally invasive surgery in the treatment of HCC

Liver surgery is the first-line treatment for hepatocellular carcinoma(HCC).Minimally invasive liver resection(MILS)has become an attractive option thanks to reduced intraoperative blood losses,shortened length of hospital stay,and similar oncological outcomes when compared to open liver resection.Nonetheless,the safety of MILS is still debated in challenging situations,such as in cirrhotic patients,difficult tumor locations,multiple or large tumors,and repeat resection.The aim of this review is to discuss current indications of laparoscopic liver resection for HCC treatment in the light of its outcomes,focusing on technical aspects of minimally invasive anatomic liver resection and state of the art of MILS in challenging situations.

Laparoscopic liver resection for hepatocellular carcinoma in patients with cirrhosis

Hepatocellular carcinoma(HCC)is a common malignant tumor and many cases occur in patients with liver cirrhosis.Although liver transplantation is the most effective treatment option,hepatectomy is still the first curative treatment option because liver transplantation is limited by the donors and high cost.In recent years,laparoscopic liver resection(LLR)has increasingly been performed in patients with liver cirrhosis,and has several advantages over open liver resection.Besides less pain and shorter hospital stay,LLR in patients with liver cirrhosis is also associated with lower incidences of postoperative liver failure and ascites because of greater preservation of collateral veins and less liver manipulation.With increasing experience,LLR for HCC located in segments 7 or 8 is now feasible,and anatomic LLR could be performed in patients with cirrhosis.Many comparative studies have shown that LLR is better than open liver resection in patients with liver cirrhosis in terms of a lower incidence of postoperative liver failure and similar patient survival.In conclusion,LLR is a promising treatment modality for HCC in patients with liver cirrhosis.