Portal vein thrombosis in liver transplantation: radiologic evaluation, risk factors, and occult diagnosis

Aim:Portal vein thrombosis(PVT)in the liver transplant recipient poses many challenges.Unfortunately,the risk factors and effects on outcomes of PVT are not well-defined.Methods:This study analyzed the experience with PVT in liver transplant program from 2007 to 2013.This included the effectiveness of PVT diagnostics and its risk factors using logistical regression.The primary endpoints were Kaplan-Meir patient and graft survival.The secondary endpoints were the length of stay(LOS),transfusion rate,and overall morbidity.Independent predictors of survival were identified using a Cox’s proportional hazards model.Results:Two hundred and sixteen consecutive liver transplant recipients were examined,and 30(13.8%)had either a total or partial PVT.Two hundred and five patients had imaging within 1 year of liver transplantation with only 7(23.3%)of the 30 PVTs identified pre-operatively.Calculated sensitivity(4.8-50%)and negative predictive values(10.5-22.2%)were poor.Only,age significantly predicted PVT[P=0.037/hazard ratio(HR)=0.95].Ninety-day-patient and graft survival for PVT was similar at 6 months,although 1-year survival was significantly lower.“Occult”PVT was not associated with inferior survival.Model for end-stage liver disease score>25(P=0.001,HR=0.49/P=0.004,HR=0.52)and age>60 years(P=0.017,HR=0.64/P=0.013,HR=0.67)were significant predictors of patient and graft survival.Although the transfusion rate was significantly greater with PVT,LOS,and morbidity were not.Conclusion:Older recipients had a greater likelihood of PVT.Diagnostic studies were not effective at excluding PVT,and occult diagnosis did not affect the outcome.PVT was not an independent predictor of mortality or graft loss,but was associated with greater blood loss but not increased LOS or morbidity.

Laparoscopic liver resection in the cirrhotic patient

Aim:The adoption of laparoscopic liver resection has been expansive in the last 2 decades with the exception of cirrhotic patients.The current study examines the outcomes of our cirrhotic resections to determine the potential limitations of this technique.Methods:Retrospective analysis of 114 cirrhotic patients.Seventy-five(65.8%)laparoscopic resections were compared to 39 open resections.Seventy-six(66.7%)resections in the series were minor resections(less than 3 segments).Surgical approach and extent of resection were analyzed using student’s t test and regression multivariate analysis with SAS.Results:The laparoscopic group had lower operative times(2.4 vs.4.8 h;P<0.001),blood loss(250 vs.609 mL;P<0.001),length of stay(4.4 vs.10.1 days;P=0.013)a nd c omplications(28%vs.48%;P=0.028).Subset analysis by technique and extent of resection identified the laparoscopic group lost the advantage in blood loss and lengths of stay when utilized in major resections.Multivariate regression analysis for blood loss further confirmed open resection(P=0.014)a nd major resection(P=0.026)a s significant i ndicators of bleeding and transfusion.Conclusion:Laparoscopic liver resection in cirrhotic patients is safe and efficacious.However,the significant variability in outcomes for major resections in cirrhotics leads us to recommend further examination of the learning curve and significant caution in the selection of cirrhotics requiring major hepatic resections.

Effect of obesity on perioperative outcomes after laparoscopic hepatectomy

Aim:Laparoscopic hepatectomy is increasing in utilization,however the procedure has not been adequately examined in the obese patient.This study aims to analyze the effect of obesity on perioperative outcomes after laparoscopic hepatectomy.Methods:Retrospective analysis of 396 laparoscopic hepatectomies in normal[body mass index(BMI)<25],overweight(BMI≥25),obese(BMI≥30),and severely obese(BMI≥35)patients using multivariate regression models to determine the risk factors for post-operative complications.Results:Normal BMI(n=78;20%),overweight(n=209;52%),obese(n=86;22%),and severely obese(n=23;6%).Demographics were similar except for a higher American Society of Anesthesiologists(ASA)score in the obese group.Estimated blood loss and operating time were greatest in the overweight group,while length of stay and complications were statistically similar between groups.Univariate analysis identified that complications were associated with weight class,ASA score,blood loss,and resection;multivariate analysis revealed ASA and transfusion were best correlated with complications.Conclusion:Obese and overweight patients have similar complication profiles to normal BMI patients while severely obese patients have a higher incidence of complications that are primarily limited to Clavien-Dindo class I and II.

Hepatoma Research:the beginning of a new forum

INTRODUCTION Liver cancer,primary hepatocellular carcinoma(HCC)or hepatoma has become the third leading cause of death from cancer worldwide.[1,2]In 2008,the GLOBOCAN reported 746,300 new cases of HCC diagnosed worldwide with 695,900 HCC-related deaths and a 1.07 incidence to mortality ratio making it the third most fatal cancer world-wide with the vast majority(84%)of cases concentrated in the developing countries in Asia and Africa.[2,3]HCC is a disparate cancer preferentially afflicting the middle to lower socio-economic segment of the world.[4]The economic cost of HCC is staggering with global expense estimated at$895.2 billion a year only followed by cardiac($753.2 billion)and cerebrovascular disease($298.2 billion).

The evolving role of laparoscopic ablation

In the last two decades,the etiology of hepatocellular cancer has shifted from hepatitis B to hepatitis C with the incidence of nonalcoholic steatohepatitis(NASH)rising dramatically.This sudden rise in NASH and newly diagnosed cases of hepatocellular cancer may represent the tip of an epidemic.Current recommendations for patients with chronic hepatitis B or hepatitis C infections should be screened with routine use of ultrasound.Despite this Surveillance,Epidemiology,and End Results,data would suggest that the average size of newly diagnosed hepatocellular cancer is beyond the Milan criteria at the time of diagnosis.In the setting of fatty liver disease and NASH,an early serologic diagnosis is not evident.