Surgical cystogastrostomy: Is it still worthwhile?

The article by Ker et al explores the treatment of peripancreatic fluid collection(PFC).The use of percutaneous drainage,endoscopy,and surgery for managing PFC are discussed.Percutaneous drainage is noted for its low risk profile,while endoscopic cystogastrostomy is more effective due to the wider orifice of the metallic stent.Surgical cystogastrostomy is a definitive treatment with a reduced need for reintervention,especially for cases with extensive collections and significant necrosis.The choice of treatment modality should be tailored to individual patient characteristics and disease factors,considering the expertise available.

Inferior vena cava reconstruction in extended right hepatectomy

To the Editor : Barcelona Clinic Liver Cancer(BCLC) Stage C hepatocellular carcinoma(HCC) with vascular invasion has been considered unresectable. However, the curative rate from systemic treatment is rather dismal. Even with the use of immunotherapy, complete remission is less than 10% [ 1 ]. On the contrary, recent advances in transplant oncology, especially in the application of liver transplant-related surgical techniques in complex liver resections, make the operation possible for patients with locally advanced HCC who were previously considered to be unresectable [ 2 ]. We hereby present the surgical management of a patient with giant HCC in right liver lobe with inferior vena cava(IVC) invasion.

Multidisciplinary approach for post-liver transplant recurrence of hepatocellular carcinoma: A proposed management algorithm

A large number of liver transplants have been performed for hepatocellular carcinoma(HCC), and recurrence is increasingly encountered. The recurrence of HCC after liver transplantation is notoriously difficult to manage. We hereby propose multi-disciplinary management with a systematic approach. The patient is jointly managed by the transplant surgeon, physician, oncologist and radiologist. Immunosuppressants should be tapered to the lowest effective dose to protect against rejection. The combination of a mammalian target of rapamycin inhibitor with a reduced calcineurin inhibitor could be considered with close monitoring of graft function and toxicity. Comprehensive staging can be performed by dual-tracer positron emission tomography-computed tomography or the combination of contrast computed tomography and a bone scan. In patients with disseminated recurrence, sorafenib confers survival benefits but is associated with significant drug toxicity. Oligo-recurrence encompasses recurrent disease that is limited in number and location so that loco-regional treatments convey disease control and survival benefits. Intra-hepatic recurrence can be managed with graft resection, but significant operative morbidity is expected. Radiofrequency ablation and stereotactic body radiation therapy(SBRT) are effective alternative strategies. In patients with more advanced hepatic disease, regional treatment with trans-arterial chemoembolization or intra-arterial Yttrium-90 can be considered. For patients with extra-hepatic oligorecurrence, loco-regional treatment can be considered if practical. Patients with more than one site of recurrence are not always contraindicated for curative treatments. Surgical resection is effective for patients with pulmonary oligo-recurrence, but adequate lung function is a prerequisite. SBRT is a non-invasive and effective modality that conveys local control to pulmonary and skeletal oligo-recurrences.

Minimally invasive donor hepatectomy, are we ready for prime time?

Minimally invasive surgery potentially reduces operative morbidities. However, pure laparoscopic approaches to donor hepatectomy have been limited by technical complexity and concerns over donor safety. Reducedwound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a minilaparotomy wound, i.e., hybrid approach, has been developed to bridge the transition to pure laparoscopic donor hepatectomy, offering some advantages of minimally invasive surgery. To date, pure laparoscopic donor left lateral sectionectomy has been validated for its safety and advantages and has become the standard in experienced centres. Pure laparoscopic approaches to major left and right liver donation have been reported for their technical feasibility in expert hands. Robotic-assisted donor hepatectomy also appears to be a valuable alternative to pure laparoscopic donor hepatectomy, providing additional ergonomic advantages to the surgeon. Existing reports derive from centres with tremendous experience in both laparoscopic hepatectomy and donor hepatectomy. The complexity of these procedures means an arduous transition from technical feasibility to reproducibility. Donor safety is paramount in living donor liver transplantation. Careful donor selection and adopting standardized techniques allow experienced transplant surgeons to safely accumulate experience and acquire proficiency. An international prospective registry will advance the understanding for the role and safety of pure laparoscopic donor hepatectomy.

Current status of associating liver partition with portal vein ligation for staged hepatectomy: Comparison with two-stage hepatectomy and strategies for better outcomes

Since its introduction in 2012,associating liver partition with portal vein ligation for staged hepatectomy(ALPPS)has significantly expanded the pool of candidates for liver resection.It offers patients with insufficient liver function a chance of a cure.ALPPS is most controversial when its high morbidity and mortality is concerned.Operative mortality is usually a result of posthepatectomy liver failure and can be minimized with careful patient selection.Elderly patients have limited reserve for tolerating the demanding operation.Patients with colorectal liver metastasis have normal liver and are ideal candidates.ALPPS for cholangiocarcinoma is technically challenging and associated with fair outcomes.Patients with hepatocellular carcinoma have chronic liver disease and limited parenchymal hypertrophy.However,in selected patients with limited hepatic fibrosis satisfactory outcomes have been produced.During the inter-stage period,serum bilirubin and creatinine level and presence of surgical complication predict mortality after stage II.Kinetic growth rate and hepatobiliary scintigraphy also guide the decision whether to postpone or omit stage II surgery.The outcomes of ALPPS have been improved by a combination of technical modifications.In patients with challenging anatomy,partial ALPPS potentially reduces morbidity,but remnant hypertrophy may compare unfavorably to a complete split.When compared to conventional two-stage hepatectomy with portal vein embolization or portal vein ligation,ALPPS offers a higher resection rate for colorectal liver metastasis without increased morbidity or mortality.While ALPPS has obvious theoretical oncological advantages over two-stage hepatectomy,the long-term outcomes are yet to be determined.

Immunotherapy after liver transplantation:Where are we now?

BACKGROUND There is limited evidence on the safety of immunotherapy use after liver transplantation and its efficacy in treating post-liver transplant hepatocellular carcinoma(HCC)recurrence.AIM To assess the safety of immunotherapy after liver transplant and its efficacy in treating post-liver transplant HCC recurrence.METHODS A literature review was performed to identify patients with prior liver transplantation and subsequent immunotherapy.We reviewed the rejection rate and risk factors of rejection.In patients treated for HCC,the oncological outcomes were evaluated including objective response rate,progression-free survival(PFS),and overall survival(OS).RESULTS We identified 25 patients from 16 publications and 3 patients from our institutional database(total n=28).The rejection rate was 32%(n=9).Early mortality occurred in 21%(n=6)and was mostly related to acute rejection(18%,n=5).Patients who developed acute rejection were given immunotherapy earlier after transplantation(median 2.9 years vs 5.3 years,P=0.02)and their graft biopsies might be more frequently programmed death ligand-1-positive(100%vs 33%,P=0.053).Their PFS(1.0±0.1 mo vs 3.5±1.1 mo,P=0.02)and OS(1.0±0.1 mo vs 19.2±5.5 mo,P=0.001)compared inferiorly to patients without rejection.Among the 19 patients treated for HCC,the rejection rate was 32%(n=6)and the overall objective response rate was 11%.The median PFS and OS were 2.5±1.0 mo and 7.3±2.7 mo after immunotherapy.CONCLUSION Rejection risk is the major obstacle to immunotherapy use in liver transplant recipients.Further studies on the potential risk factors of rejection are warranted.

Initial experience with stereotactic body radiotherapy for intrahepatic hepatocellular carcinoma recurrence after liver transplantation

BACKGROUND Graft hepatocellular carcinoma(HCC)recurrence after liver transplant is more frequently encountered.Graft hepatectomy is technically challenging and is associated with high morbidity.Stereotactic body radiation therapy(SBRT)has been shown to be safe and effective for the treatment of primary HCC.However,its role in HCC recurrence in a liver graft remains unclear.AIM To evaluate the safety and efficacy of SBRT for the treatment of graft HCC recurrence after liver transplantation.METHODS A retrospective study was conducted.From 2012 to 2018,6 patients with intrahepatic HCC recurrence after liver transplant were treated with SBRT at Queen Mary Hospital,the University of Hong Kong.The primary outcome was time to overall disease progression and secondary outcomes were time to local progression and best local response,as assessed with the Modified response Evaluation Criteria for Solid Tumours criteria.Patients were monitored for treatment related toxicities and graft dysfunction.RESULTS A total of 9 treatment courses were given for 13 tumours.The median tumour size was 2.3 cm(range 0.7-3.6 cm).Two(22%)patients had inferior vena cava tumour thrombus.The best local treatment response was:5(55%)complete response,1(11%)partial response and 3(33%)stable disease.After a median follow up duration of 15.5 mo,no local progression or mortality was yet observed.The median time to overall disease progression was 6.5 mo.There were 6 regional progression in the liver graft(67%)and 2 distant progression in the lung(22%).There was no grade 3 or above toxicity and there was no graft dysfunction after SBRT.CONCLUSION SBRT appears to be safe in this context.Regional progression is the mode of failure.

Clinical factors affecting rejection rates in liver transplantation

With improvements in survival, liver trans- plant recipients now suffer more morbidity from long-term immunosuppression. Considerations were given to develop individualized immunosuppression based on their risk of re- jection. METHOD： We retrospectively analyzed the data of 788 liver transplants performed during the period from October 1991 to December 2011 to study the relationship between acute cel- lular rejection （ACR） and various clinical factors. RESULTS： Multivariate analysis showed that older age （P=0.04, OR=0.982）, chronic hepatitis B virus infection （P=0.005, OR= 0.574）, living donor liver transplantation （P=0.02, OR=0.648） and use of interleukin-2 receptor antagonist on induction （P〈0.001, OR=0.401） were associated with fewer ACRs. Patients with fulminant liver failure （P=.004, OR=4.05） were more likely to develop moderate to severe grade ACR. CONCLUSIONS： Liver transplant recipients with older age, chronic hepatitis B virus infection, living donor liver trans- plantation and use of interleukin-2 receptor antagonist on in- duction have fewer ACR. Patients transplanted for fulminant liver failure are at higher risk of moderate to severe grade ACR. These results provide theoretical framework for developing individualized immunosuppression.

Mammalian target of rapamycin inhibitors after post-transplant hepatocellular carcinoma recurrence:Is it too late?

BACKGROUND Mammalian target of rapamycin(mTOR)inhibitors have been shown to reduce the risk of tumour recurrence after liver transplantation for hepatocellular carcinoma(HCC).However,their role in established post-transplant HCC recurrence is uncertain.AIM To investigate whether mTOR inhibitor offers a survival benefit in posttransplant HCC recurrence.METHODS A retrospective study of 143 patients who developed HCC recurrence after liver transplantation was performed.They were divided into 2 groups based on whether they had received mTOR inhibitor-based immunosuppression.The primary endpoint was post-recurrence survival.RESULTS Seventy-nine(55%)patients received an mTOR inhibitor-based immunosuppressive regime,while 64(45%)patients did not.The mTOR inhibitor group had a lower number of recurrent tumours(2 vs 5,P=0.02)and received more active treatments including radiotherapy(39 vs 22%,P=0.03)and targeted therapy(59 vs 23%,P<0.001).The median post-recurrence survival was 21.0±4.1 mo in the mTOR inhibitor group and 11.2±2.5 mo in the control group.Multivariate Cox regression analysis confirmed that mTOR inhibitor therapy was independently associated with improved post-recurrence survival(P=0.04,OR=0.482,95%CI:0.241-0.966).The number of recurrent tumours and use of other treatment modalities did not affect survival.No survival difference was observed between mTOR inhibitor monotherapy and combination therapy with calcineurin inhibitor.CONCLUSION mTOR inhibitors prolonged survival after post-transplant HCC recurrence.

Partial portal vein arterialization using right gastroepiploic artery:A novel solution for portal hypoperfusion

To the Editor:Establishing dual arterial and portal inflow is essential for liver transplantation[1].Inadequate portal inflow compromises graft function and graft survival[2].Portal hypoperfusion is usually a consequence of spontaneous portosystemic shunt,ligation of which

Hepatectomy bridges to transplant—the road to cure?

Liver transplantation and hepatic resection are effective surgical strategies for hepatocellular carcinoma(HCC).In the current issue of Annals of Surgery,Professor Pinna and colleagues applied a cure model to compare both treatments(1).Comparison was made in terms of cure rate.Interestingly,curation has never been concisely defined in clinical practise.In the standard survival model,patients are considered disease-free after R0 resection but are always at risk of recurrence.It is arguable,particularly for HCC,whether disease clearance equates curation,as more than half of patients recur in 5 years after radical resection(2).In epidemiology,statistical cure is achieved when the mortality of the patients treated for a specific disease return to that in the general population(3).However,statistical cure is neither practical in clinical sense,as patients surviving with disease are also considered cured.