Life made easy:simplifying reconstruction for dual portal veins in adult right lobe live donor liver transplantation

In live donor liver transplantation, anatomical anomalies of the portal vein are more frequently encountered in right lobe than left lobe grafts. Of these, a dual portal vein is one of the most common anatomical anomalies encountered. We hereby report our method of using a recipient portal vein patch after venoplasty for reconstruction in a right lobe graft with separate anterior and posterior portal vein branches.

Asia's first combined liver transplant and aortic valve replacement

To the editor:Liver transplantation is the only cure for patients with endstage liver disease.It is however an ultra-major surgery which is physiologically challenging to the cardiopulmonary function of the patients.Hence,in patients who also have valvular heart disease or coronary artery disease,liver transplantation would be con-

Role of C11-FDG dual-tracer PET-CT scan in metastatic screening of hepatocellular carcinoma-a cost-effectiveness analysis

Background:We aimed to identify predictive factors for positron emission tomography(PET)-detected hepatocellular carcinoma(HCC)metastasis and a cost-effective approach to preoperative PET-computed tomography(CT)for detecting metastasis.Methods:Clinicopathological and survival data of HCC patients having PET-CT with 18F-fludeoxyglucose(FDG)and 11C-acetate(ACT)following contrast-enhanced CT/magnetic resonance imaging(MRI)for preoperative tumor staging were reviewed.Binary logistic regression was performed to identify predictive factors for PET-detected metastasis.A cost-benefit analysis model was built for the incurred costs and the impact of PET-CT findings on treatment strategy was studied.Results:Totally 152 patients were analyzed.Dual-tracer PET-CT detected metastasis in 17 patients(11%).By multivariate analysis,alpha-fetoprotein(AFP)≥400 ng/mL[relative risk(RR):4.30,95%confidence interval(CI):1.41-13.15,P=0.011]and bilobar disease(RR:3.94,95%CI:1.24-12.52,P=0.014)were independent predictive factors for PET-detected metastasis.PET-CT findings altered the treatment strategy for 12 patients(7.9%);three partial hepatectomies,eight episodes of transarterial chemoembolization(TACE)and one episode of ablation were avoided,with an estimated cost-saving of US$91,000,$150,000 and$10,600 respectively.Had the PET-CT been performed only for patients with AFP≥400 ng/mL or bilobar disease(n=74),metastasis would have been confirmed in 14 patients(18.9%),and the cost-saving per patient was estimated at US$1,070.Conclusions:Dual-tracer PET-CT is cost-effective and useful for preoperative HCC staging in patients with AFP≥400 ng/mL or bilobar disease.Its routine use in preoperative workup for all HCC patients is not recommended.Unilobar disease with AFP<400 ng/mL can achieve good negative predictive value for PET-detected metastasis.Screening patients with either factor can avoid unnecessary procedures and is thus cost-effective for preoperative HCC workup.

Surgical strategy for huge and advanced hepatocellular carcinoma in Hong Kong

In Hong Kong, surgical resection is the core curative treatment for huge and advanced hepatocellular carcinoma (HCC). For tumors measuring 10 cm or above, major hepatectomy is usually required, but a future liver remnant not large enough will preclude the operation. Hypertrophy of future liver remnant is a way to render more patients operable, and measures include portal vein embolization and associating liver partition and portal vein ligation for staged hepatectomy. For HCC that has invaded a major vessel, en bloc resection with immediate vessel reconstruction is necessary if thrombectomy would not suffice. In case of bilobar involvement, radiofrequency ablation is a useful adjuctive therapy. In the treatment of extrahepatic metastasis, metastasectomy offers a cure to properly selected patients.