High-intensity focused ultrasound ablation:An effective bridging therapy for hepatocellular carcinoma patients

AIM:To analyze whether high-intensity focused ultrasound(HIFU) ablation is an effective bridging therapy for patients with hepatocellular carcinoma(HCC).METHODS:From January 2007 to December 2010,49 consecutive HCC patients were listed for liver transplantation(UCSF criteria).The median waiting time for transplantation was 9.5 mo.Twenty-nine patients received transarterial chemoembolization(TACE) as a bringing therapy and 16 patients received no treatment before transplantation.Five patients received HIFU ablation as a bridging therapy.Another five patients with the same tumor staging(within the UCSF criteria) who received HIFU ablation but not on the transplant list were included for comparison.Patients were comparable in terms of Child-Pugh and model for end-stage liver disease scores,tumor size and number,and cause of cirrhosis.RESULTS:The HIFU group and TACE group showed no difference in terms of tumor size and tumor number.One patient in the HIFU group and no patient in the TACE group had gross ascites.The median hospital stay was 1 d(range,1-21 d) in the TACE group and two days(range,1-9 d) in the HIFU group(P < 0.000).No HIFU-related complication occurred.In the HIFU group,nine patients(90%) had complete response and one patient(10%) had partial response to the treatment.In the TACE group,only one patient(3%) had response to the treatment while 14 patients(48%) had stable disease and 14 patients(48%) had progressive disease(P = 0.00).Seven patients in the TACE group and no patient in the HIFU group dropped out from the transplant waiting list(P = 0.559).CONCLUSION:HIFU ablation is safe and effective in the treatment of HCC for patients with advanced cirrhosis.It may reduce the drop-out rate of liver transplant candidate.

Prevention of recurrent hepatitis B infection after liver transplantation

BACKGROUND:Recurrence of hepatitis B virus(HBV) infection after liver transplantation can lead to graft loss and a reduction in long-term survival.The purpose of this review is to summarize the current therapeutic options for preventing HBV recurrence in liver transplant recipients.DATA SOURCES:Up to January 2013,studies that were published in MEDLINE and EMBASE on prevention of HBV recurrence after liver transplantation were reviewed.RESULTS:There have been remarkable advancements in the past two decades on the prevention of HBV recurrence after liver transplantation,from the discovery of hepatitis B immune globulin(HBIG) and lamivudine monotherapy to the combination therapy using HBIG and lamivudine.With the development of newer and stronger antiviral agents,the need for life-long HBIG is doubtful.With their low resistance profile,oral antiviral prophylaxis using these new agents alone is sufficient and is associated with excellent outcome.CONCLUSIONS:Restoration of host HBV immunity with adoptive immunity transfer and vaccination may represent the ultimate strategy to withdraw prophylactic treatment and to achieve a drug free regimen against HBV recurrence after liver transplantation.

Survival outcomes of right-lobe living donor liver transplantation for patients with high Model for End-stage Liver Disease scores

BACKGROUND: Controversy exists over whether living donor liver transplantation (LDLT) should be offered to patients with high Model for End-stage Liver Disease (MELD) scores. This study tried to determine whether a high MELD score would result in inferior outcomes of right-lobe LDLT. METHODS: Among 411 consecutive patients who received right-lobe LDLT at our center, 143 were included in this study. The patients were divided into two groups according to their MELD scores: a high-score group (MELD score ≥25; n=75) and a low-score group (MELD score 【25; n=68). Their demographic data and perioperative conditions were compared. Univariable and multivariable analyses were performed to identify risk factors affecting patient survival. RESULTS: In the high-score group, more patients required preoperative intensive care unit admission (49.3% vs 2.9%; P【0.001), mechanical ventilation (21.3% vs 0%; P【0.001), or hemodialysis (13.3% vs 0%; P=0.005); the waiting time before LDLT was shorter (4 vs 66 days; P【0.001); more blood was transfused during operation (7 vs 2 units; P【0.001); patients stayed longer in the intensive care unit (6 vs 3 days; P【0.001) and hospital (21 vs 15 days; P=0.015) after transplantation;more patients developed early postoperative complications (69.3% vs 50.0%; P=0.018); and values of postoperative peak blood parameters were higher. However, the two groups had comparable hospital mortality. Graft survival and patient overall survival at one year (94.7% vs 95.6%; 95.9% vs 96.9%), three years (91.9% vs 92.6%; 93.2% vs 95.3%), and five years (90.2% vs 90.2%; 93.2% vs 95.3%) were also similar between the groups. CONCLUSIONS: Although the high-score group had signifi-cantly more early postoperative complications, the two groups had comparable hospital mortality and similar satisfactory rates of graft survival and patient overall survival. Therefore, a high MELD score should not be a contraindication to right-lobe LDLT if donor risk and recipient benefit are taken into full account.

Outcomes of right-lobe and left-lobe living-donor liver transplantations using small-for-size grafts

AIM To analyze the outcomes of living-donor liver transplantation(LDLT) using left-lobe(LL) or right-lobe(RL) small-for-size(SFS) grafts.METHODS Prospectively collected data of adult patients who underwent LDLT at our hospital in the period from January 2003 to December 2013 were reviewed. The patients were divided into the RL-LDLT group and the LL-LDLT group. The two groups were compared in terms of short-and long-term outcomes, including incidence of postoperative complication, graft function, graft survival, and patient survival. A SFS graft was defined as a graft with a ratio of graft weight(GW) to recipient standard liver volume(RSLV)(GW/RSLV) of < 50%. The Urata formula was used to estimate RSLV.RESULTS Totally 218 patients were included for analysis, with 199 patients in the RL-LDLT group and 19 patients in the LL-LDLT group. The two groups were similar in terms of age(median, 53 years in the RL-LDLT group and 52 years in the LL-LDLT group, P = 0.997) but had significantly different ratios of men to women(165:34 in the RL-LDLT group and 8:11 in the LL-LDLT group, P < 0.0001). The two groups were also significantly different in GW(P < 0.0001), GW/RSLV(P < 0.0001), and graft cold ischemic time(P = 0.007). When it comes to postoperative complication, the groups were comparable(P = 0.105). Five patients died in hospital,4(2%) in the RL-LDLT group and 1(5.3%) in the LLLDLT group(P = 0.918). There were 38 graft losses, 33(16.6%) in the RL-LDLT group and 5(26.3%) in the LL-LDLT group(P = 0.452). The 5-year graft survival rate was significantly better in the RL-LDLT group(95.2% vs 89.5%, P = 0.049). The two groups had similar 5-year patient survival rates(RL-LDLT: 86.8%, LL-LDLT: 89.5%, P = 0.476).CONCLUSION The use of SFS graft in LDLT requires careful tailormade surgical planning and meticulous operation. LLLDLT can be a good alternative to RL-LDLT with similar recipient outcomes but a lower donor risk. Further research into different patient conditions is needed in order to validate the use of LL graft.

Donor ductal anomaly is not a contraindication to right liver lobe donation

Background:Data of living-donor liver transplantation(LDLT)suggested that donor ductal anomaly may contribute to postoperative biliary complications in recipients and in donors.This retrospective study aimed to determine if the occurrence of postoperative biliary stricture in donors or recipients in rightlobe LDLT(RLDLT)is related to donor biliary anatomy type.Methods:We analyzed our RLDLT recipients’clinical data and those of their graft donors.The recipients were divided into 2 groups:with and without postoperative biliary stricture.The 2 groups were compared.The primary endpoints were donor biliary anatomy type and postoperative biliary complication incidence;the secondary endpoints were 1-,3-and 5-year graft and patient survival rates.Results:Totally 127 patients were included in the study;25(19.7%)of them developed biliary anastomotic stricture.In these 25 patients,16 had type A biliary anatomy,3 had type B,2 had type C,3 had type D,and 1 had type E.In the 127 donors,96(75.6%)had type A biliary anatomy,13(10.2%)had type B,6(4.7%)had type C,10(7.9%)had type D,and 2(1.6%)had type E.Biliary stricture was seen in 2 donors,who had type A biliary anatomy.None of the recipients or donors developed bile leakage.No association between the occurrence of postoperative biliary stricture and donor biliary anatomy type was found(P=0.527).Conclusions:The incidence of biliary stricture in donors or recipients after RLDLT was not related to donor biliary anatomy type.As postoperative complications were similar in whatever type of donor bile duct anatomy,donor ductal anomaly should not be considered a contraindication to donation of right liver lobe.

Recurrent pyogenic cholangitis:An indication for liver transplantation

To the Editor:Recurrent pyogenic cholangitis(RPC),also known as Hong Kong disease[1],is an unique disease entity with a decreasing incidence.It is characterized by the formation of intrahepatic biliary pigmented stones,which results in stricturing of the biliary tree followed by obstruction and repeated attacks of cholangitis.

Emergency ABO-incompatible living donor liver transplant for patients with ultrahigh MELD scores

To the Editor:A 49-year-old Chinese man with treatment-naive chronic hepatitis B presented with a one-week history of jaundice when admitted to our hospital.On admission,his bilirubin was 704μmol/L,alanine aminotransferase 180 U/L,international normalized ratio 2.4,creatinine 140μmol/L,and Model for End-stage Liver Disease(MELD)score 35.His serum HBV DNA was 64.7 IU/mL,and he was commenced on entecavir.Nonetheless,he developed acute-onchronic liver failure on day 28 with grade 2 hepatic encephalopathy and a MELD score of 40(bilirubin 709μmol/L,international normalized ratio 3.3,creatinine 181μmol/L).