Preoperative predictors of portal vein thrombosis after splenectomy with periesophagogastric devascularization

AIM:To evaluate the predictive value of preoperative predictors for portal vein thrombosis(PVT)after splenectomy with periesophagogastric devascularization.METHODS:In this prospective study,69 continuous patients with portal hypertension caused by hepatitis B cirrhosis underwent splenectomy with periesophagogastric devascularization in West China Hospital of Sichuan University from January 2007 to August 2010.The portal vein flow velocity and the diameter of portal vein were measured by Doppler sonography.The hepatic congestion index and the ratio of velocity and diameter were calculated before operation.The prothrombin time(PT)and platelet(PLT)levels were measured before and after operation.The patients'spleens were weighed postoperatively.RESULTS:The diameter of portal vein was negatively correlated with the portal vein flow velocity(P<0.05).Thirty-three cases(47.83%)suffered from postoperative PVT.There was no statistically significant difference in the Child-Pugh score,the spleen weights,the PT,or PLT levels between patients with PVT and without PVT.Receiver operating characteristic curves showed four variables(portal vein flow velocity,the ratio of velocity and diameter,hepatic congestion index and diameter of portal vein)could be used as preoperative predictors of postoperative portal vein thrombosis.The respective values of the area under the curve were 0.865,0.893,0.884 and 0.742,and the respective cut-off values(24.45 cm/s,19.4333/s,0.1138 cm/s-1 and 13.5 mm) were of diagnostically efficient,generating sensitivity values of 87.9%,93.9%,87.9%and 81.8%,respectively,specificities of 75%,77.8%,86.1%and 63.9%,respectively.CONCLUSION:The ratio of velocity and diameter was the most accurate preoperative predictor of portal vein thrombosis after splenectomy with periesophagogastric devascularization in hepatitis B cirrhosis-related portal hypertension.

Value of α-fetoprotein in association with clinicopathological features of hepatocellular carcinoma

AIM:To explore the relationship between α-fetoprotein(AFP) and various clinicopathological variables and different staging system of hepatocellular carcinoma(HCC) thoroughly.METHODS:A retrospective cohort study of consecutive patients diagnosed with HCC between January 2008 and December 2009 in West China Hospital was enrolled in our study.The association of serum AFP values with the HCC clinicopathological features was analysed by univariate and multivariate analysis,such as status of hepatitis B virus(HBV) infection,tumor size,tumor number,vascular invasion and degree of tumor differentiation.Also,patients were divided into four groups at the time of enrollment according to different cutoff values for serum value of AFP(≤ 20 μg/L,21-400 μg/L,401-800 μg/L,and ≥ 801 μg/L),to compare the positive rate of patient among four groups stratified by various clinicopathological variables.And the correlation of different kinds of tumor staging systems,such as TNM,Barcelona Clinic Liver Cancer(BCLC) staging classification and China staging,were compared with the serum concentration of AFP.RESULTS:A total of 2304 HCC patients were enrolled in this study totally;the mean serum level of AFP was 555.3 ± 546.6 μg/L.AFP levels were within the normal range(< 20 μg/L) in 27.4%(n = 631) of all the cases.81.4%(n = 1875) patients were infected with HBV,and those patients had much higher serum AFP level compared with non-HBV infection ones(573.9 ± 547.7 μg/L vs 398.4 ± 522.3 μg/L,P < 0.001).The AFP level in tumors ≥ 10 cm(808.4 ± 529.2 μg/L) was significantly higher(P < 0.001) than those with tumor size 5-10 cm(499.5 ± 536.4 μg/L) and with tumor size ≤ 5 cm(444.9 ± 514.2 μg/L).AFP levels increased significantly in patients with vascular invasion(694.1 ± 546.9 μg/L vs 502.1 ± 543.1 μg/L,P < 0.001).Patients with low tumor cell differentiation(559.2 ± 545.7 μg/L) had the significantly(P = 0.007) highest AFP level compared with high differentiation(207.3 ± 420.8 μg/L) and intermediate differentiation(527.9 ± 538.4 μg/L).In the multiple variables analysis,low tumor cell differentiation [OR 6.362,95%CI:2.891-15.382,P = 0.006] and tumor size(≥ 10 cm)(OR 5.215,95%CI:1.426-13.151,P = 0.012) were independent predictors of elevated AFP concentrations(AFP > 400 μg/L).Serum AFP levels differed significantly(P < 0.001) in the D stage of BCLC(625.7 ± 529.8 μg/L) compared with stage A(506.2 ± 537.4 μg/L) and B(590.1 ± 551.1 μg/L).CONCLUSION:HCC differentiation,size and vascular invasion have strong relationships with AFP,poor differentiation and HCC size ≥ 10 cm are independent predictors of elevated AFP.BCLC shows better relationship with

Neutrophil-lymphocyte ratio predicts the prognosis of patients with hepatocellular carcinoma after liver transplantation

AIM:To determine whether an elevated neutrophillymphocyte ratio(NLR)is negatively associated with tumor recurrence in patients with hepatitis B virus(HBV)-related hepatocellular carcinoma(HCC)after liver transplantation(LT),and to determine the optimal predictive NLR cut-off value.METHODS:The data of HCC patients who had undergone LT came from the China Liver Transplant Registry database.We collected data from 326 liver cancer patients who had undergone LT at our medical center.We divided the patients into groups based on their NLRs(3,4 or 5).We then compared the clinicopathological data and long-time survival between these groups.Meanwhile,we used receiver operating characteristic analysis to determine the optimal NLR cut-off.RESULTS:Of 280 HCC patients included in this study,263 were HBV positive.Patients with an NLR<3 and patients with an NLR≥3 but<4 showed no significant differences in overall survival(OS)(P=0.212)or disease-free survival(DFS)(P=0.601).Patients with an NLR≥4 but<5 and patients with an NLR≥5also showed no significant differences in OS(P=0.208)or DFS(P=0.618).The 1-,3-and 5-year OS rates of patients with an NLR<4 vs an NLR≥4 were 87.8%,63.8%and 61.5%vs 73.9%,36.7%and 30.3%,respectively(P<0.001).The 1-,3-and 5-year DFS rates of patients with an NLR<4 vs NLR≥4 were 83.9%,62.9%and 60.7%vs 64.9%,30.1%and 30.1%,respectively(P<0.001).Univariate and multivariate analyses demonstrated that three factors,including NLR≥4(P=0.002),were significant predictors of tumor recurrence in HCC patients after LT.CONCLUSION:A preoperative elevated NLR significantly increased the risk for tumor recurrence in HCC patients after LT.

Hemihepatic versus total hepatic inflow occlusion during hepatectomy:A systematic review and meta-analysis

AIM： To evaluate the clinical outcomes of patients undergoing hepatectomy with hemihepatic vascular occlusion （HHO） compared with total hepatic inflow occlusion （THO）. METHODS： Randomized controlled trials （RCTs） co- mparing hemihepatic vascular occlusion and total he- patic inflow occlusion were included by a systematic literature search. Two authors independently assessed the trials for inclusion and extracted the data. A meta- analysis was conducted to estimate blood loss, transfu- sion requirement, and liver injury based on the levels of aspartate aminotransferase （AST） and alanine arni- notransferase （ALT）. Either the fixed effects model or random effects model was used. RESULTS- Four RCTs including 338 patients met the predefined inclusion criteria. A total of 167 patients were treated with THO and 171 with HHO. Metaanalysis of AST levels on postoperative day 1 indicated higher levels in the THO group with weighted mean dif- ference （WMD） 342.27; 95% confidence intervals （CI） 217.28-467.26; P = 0.00001; I2 = 16%. Meta-analysis showed no significant difference between THO group and HHO group on blood loss, transfusion requirement, mortality, morbidity, operating time, ischemic duration, hospital stay, ALT levels on postoperative day 1, 3 and 7 and AST levels on postoperative day 3 and 7. CONCLUSION： Hemihepatic vascular occlusion does not offer satisfying benefit to the patients undergoing hepatic resection. However, they have less liver injury after liver resections.

Bile leakage test in liver resection:A systematic review and meta-analysis

AIM:To assess systematically the safety and efficacy of bile leakage test in liver resection.METHODS:Randomized controlled trials and controlled clinical trials involving the bile leakage test were included in a systematic literature search.Two authors independently assessed the studies for inclusion and extracted the data.A meta-analysis was conducted to estimate postoperative bile leakage,intraoperative positive bile leakage,and complications.We used either the fixed-effects or random-effects model.RESULTS:Eight studies involving a total of 1253 patients were included and they all involved the bile leakage test in liver resection.The bile leakage test group was associated with a significant reduction in bile leakage compared with the non-bile leakage test group(RR=0.39,95%CI:0.23-0.67;I2=3%).The white test had superiority for detection of intraoperative bile leakage compared with the saline solution test(RR=2.38,95%CI:1.24-4.56,P=0.009).No significant intergroup differences were observed in total number of complications,ileus,liver failure,intraperitoneal hemorrhage,pulmonary disorder,abdominal infection,and wound infection.CONCLUSION:The bile leakage test reduced postoperative bile leakage and did not increase incidence of complications.Fat emulsion is the best choice of solution for the test.

Minimizing tacrolimus decreases the risk of new-onset diabetes mellitus after liver transplantation

AbstractAIM： To investigate the impact of minimum tacrolimus（TAC） on new-onset diabetes mellitus （NODM） afterliver transplantation （LT）.METHODS： We retrospectively analyzed the data of973 liver transplant recipients between March 1999and September 2014 in West China Hospital LiverTransplantation Center. Following the exclusion ofineligible recipients, 528 recipients with a TAC-dominantregimen were included in our study. We calculatedand determined the mean trough concentration ofTAC （cTAC） in the year of diabetes diagnosis in NODMrecipients or in the last year of the follow-up in non-NODM recipients. A cutoff of mean cTAC value forpredicting NODM 6 mo after LT was identified usinga receptor operating characteristic curve. TAC-relatedcomplications after LT was evaluated by χ^2 test, andthe overall and allograft survival was evaluated usingthe Kaplan-Meier method. Risk factors for NODM afterLT were examined by univariate and multivariate Cox regression.RESULTS： Of the 528 transplant recipients, 131（24.8%） developed NODM after 6 mo after LT, andthe cumulative incidence of NODM progressivelyincreased. The mean cTAC of NODM group recipientswas significantly higher than that of recipients in thenon-NODM group （7.66 ± 3.41 ng/mL vs 4.47 ± 2.22ng/mL, P 〈 0.05）. Furthermore, NODM group recipientshad lower 1-, 5-, 10-year overall survival rates （86.7%,71.3%, and 61.1% vs 94.7%, 86.1%, and 83.7%, P 〈0.05） and allograft survival rates （92.8%, 84.6%, and75.7% vs 96.1%, 91%, and 86.1%, P 〈 0.05） thanthe others. The best cutoff of mean cTAC for predictingNODM was 5.89 ng/mL after 6 mo after LT. Multivariateanalysis showed that old age at the time of LT （〉 50years）, hypertension pre-LT, and high mean cTAC （≥5.89 ng/mL） after 6 mo after LT were independent riskfactors for developing NODM. Concurrently, recipientswith a low cTAC （〈 5.89 ng/mL） were less likely tobecome obese （21.3% vs 30.2%, P 〈 0.05） or todevelop dyslipidemia （27.5% vs 44.8%, P 〈0.05）,chronic kidney dysfunction （14.6% vs 22.7%, P 〈 0.05）,and moderate to severe infection （24.7% vs 33.1%, P〈 0.05） after LT than recipients in the high mean cTACgroup. However, the two groups showed no significantdifference in the incidence of acute and chronicrejection, hypertension, cardiovascular events and newonsetmalignancy.CONCLUSION： A minimal TAC regimen can decreasethe risk of long-term NODM after LT. Maintaining a cTACvalue below 5.89 ng/mL after LT is safe and beneficial.

Contrast-enhanced ultrasound:Improving the preoperative staging of hepatocellular carcinoma and guiding individual treatment

AIM: To investigate the clinical role of contrast-enhanced ultrasound (CEUS) combined with contrast-enhanced computed tomography (CE-CT) or magnetic resonance imaging to improve the preoperative staging of hepatocellular carcinoma (HCC) and guide surgical decision-making. METHODS: Sixty-nine patients who underwent liver resection for HCC in our center were enrolled prospectively in the study. CEUS and CE-CT/MRI were performed before surgery. Intraoperative ultrasound (IOUS) was carried out after liver mobilization. Lesions depicted by each imaging modality were counted and mapped. To investigate the impact of tumor size on the study, we divided the patients into two groups, the 'Smaller group'(S-group, <= 5 cm in diameter) and the 'Largergroup' (L-group, > 5 cm in diameter). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CE-CT/MRI, CEUS, IOUS, CEUS+CE-CT/MRI and the tumor node metastasis staging of tumors were calculated and compared. Changes in the surgical strategy as a result of CEUS and IOUS were analyzed. RESULTS: One hundred and twenty-seven nodules, comprising 94 HCCs confirmed by histopathology and 33 benign lesions confirmed by histopathology and follow-up, were identified in 69 patients. The overall diagnostic sensitivity rates of CE-CT/MRI, CEUS, IOUS and CEUS+ CE-CT/MRI were 78.7%, 89.4%, 89.4% and 89.4%, respectively. There was a significant difference between CEUS + CE-CT/MRI and CE-CT/MRI (P = 0.046). Combining CEUS with CT or MRI increased, the diagnostic specificity compared with CT/MRI, CEUS and IOUS, and this difference was statistically significant (100%, 72.7%, 97.0%, and 69.7%, P = 0.004, P = 0.002, P = 0.002, respectively). The diagnostic accuracy was significantly higher for CEUS + CT/MRI compared with CT/MRI (92.1% vs 77.2%, P = 0.001). The TNM staging of tumors based on CEUS + CE-CT/MRI approximated to the final pathological TNM staging (P = 0.977). There was a significant difference in the accuracy of TNM staging when comparing CEUS + CECT/MRI with CE-CT/MRI (P = 0.002). Before surgery, strategies were changed in 15.9% (11/69) of patients as a result of CEUS. Finally, only 5.7% (4/69) of surgical strategies were changed because of IOUS findings. In the S-group, CEUS revealed 12 false positive lesions, including seven false positive lesions that were diagnosed by preoperative imaging examinations and five by IOUS. In contrast, in the L-group, IUOS revealed eight new malignant lesions; six of these lesions were true HCCs that were also identified by preoperative CEUS. CONCLUSION: CEUS combined with CT or MRI improves the accuracy of preoperative staging for hepatocellular carcinoma and may help to guide individualized treatment for patients with HCC. CEUS may better identify non-malignant lesions in patients with small tumors and discover new malignant lesions in patients with large tumors. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

Surgical vs percutaneous radiofrequency ablation for hepatocellular carcinoma in dangerous locations

AIM:To compare the long-term outcome of percutaneous vs surgical radiofrequency ablation(RFA) for hepatocellular carcinoma(HCC) in dangerous locations.METHODS:One hundred and sixty-two patients with HCC in dangerous locations treated with percutaneous or surgical RFA were enrolled in this study.The patients were divided into percutaneous RFA group and surgical RFA group.After the patients were regularly followed up for a long time,their curative rate,hospital stay time,postoperative complications and 5-year local tumor progression were compared and analyzed.RESULTS:No significant difference was observed in curative rate between the two groups(91.3% vs 96.8%,P = 0.841).The hospital stay time was longer and more analgesics were required while the incidence of bile duct injury and RFA-related hemorrhage was lower in surgical RFA group than in percutaneous RFA group(P < 0.05).The local progression rate of HCC in dangerous locations was significantly lower in surgical RFA group than in percutaneous RFA group(P = 0.05).The relative risk of local tumor progression was 14.315 in percutaneous RFA group.CONCLUSION:The incidence of severe postoperative complications and local tumor progression is lower after surgical RFA than after percutaneous RFA.

Retrospective study of steroid therapy for patients with autoimmune pancreatitis in a Chinese population

AIM:To explore the optimal steroid therapeutic strategy for autoimmune pancreatitis(AIP).METHODS:This study was conducted retrospectively in two large institutions in China.Patients with clinically,radiologically and biochemically diagnosed AIP were enrolled.The performed radiological investigations and biochemical tests,the regimen of the given steroid treatment,remission and relapse whether with and without steroid therapy were analyzed.RESULTS:Twenty-eight patients with AIP received steroid treatment,while 40 patients were treated surgically by pancreatoduodenectomy,distal pancreatectomy and choledochojejunostomy,radiofrequency ablation for the enlarged pancreatic head,percutaneous transhepatic biliary drainage and endoscopic biliary drainage.The starting oral prednisolone dose was 30 mg/d in 18(64.3%) patients and 40 mg/d in 10(35.7%) patients administered for 3 wk.The remission rate of AIP patients with steroid treatment(96.4%) was significantly higher than in those without steroid treatment(75%).Maintenance therapy(oral prednisolone dose 5 mg/d) was performed after remission for at least 6-12 mo to complete the treatment course.Similarly,the relapse rate was significantly lower in AIP patients with steroid treatment(28.6%) than in those without steroid treatment(42.5%).Steroid re-treatment was effective in all relapsed patients with or without steroid therapy.CONCLUSION:Steroid therapy should be considered in all patients with active inflammatory phase of AIP.However,the optimal regimen still should be trailed in larger numbers of patients with AIP.

Liver resection in hepatitis B related-hepatocellular carcinoma: Clinical outcomes and safety in elderly patients

AIM: To compare the morbidity and mortality in young and elderly hepatocellular carcinoma (HCC) patients undergoing liver resection. METHODS: We retrospectively enrolled 1543 consecutive hepatitis B (HBV)-related HCC patients undergoing elective hepatic resection in our cohort, including 207 elderly patients (>= 65 years) and 1336 younger patients (< 65 years). Patient characteristics and clinical outcomes after liver resection were compared between the two groups. RESULTS: Elderly patients had more preoperative comorbidities and lower alanine aminotransferase and aspartate aminotransferase levels. Positive rates for hepatitis B surface antigen (P < 0.001), hepatitis B e antigen (P < 0.001) and HBV DNA (P = 0.017) were more common in younger patients. Overall complications and their severity classified using the Clavien system were similar in the two groups (33.3% vs 29.6%, P = 0.271). Elderly patients had a higher rate of postoperative cardiovascular complications (3.9% vs 0.6%, P = 0.001), neurological complications (2.9% vs 0.4%, P < 0.001) and mortality (3.4% vs 1.2%, P = 0.035), and had more hospital stay requirement (13 d vs 12 d, P < 0.001) and more intensive care unit stay (36.7% vs 27.8%, P = 0.008) compared with younger patients. However, postoperative hepatic insufficiency was more common in the younger group (7.7% vs 3.4%, P = 0.024). CONCLUSION: Hepatectomy can be safely performed in elderly patients. Age should not be regarded as a contraindication to liver resection with expected higher complication and mortality rates. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

Analysis of infections in the first 3-month after living donor liver transplantation

AIM:To identify factors related to serious postoperative bacterial and fungal infections in the first 3 mo after living donor liver transplantation(LDLT).METHODS:In the present study,the data of 207 patients from 2004 to 2011 were reviewed.The pre-,intra-and post-operative factors were statistically analyzed.All transplantations were approved by the ethics committee of West China Hospital,Sichuan University.Patients with definitely preoperative infections and infections within 48 h after transplantation were excluded from current study.All potential risk factors were analyzed using univariate analyses.Factors significant at a P < 0.10 in the univariate analyses were involved in the multivariate analyses.The diagnostic accuracy of the identified risk factors was evaluated using receiver operating curve.RESULTS:The serious bacterial and fungal infection rates were 14.01% and 4.35% respectively.Enterococcus faecium was the predominant bacterial pathogen,whereas Candida albicans was the most common fungal pathogen.Lung was the most common infection site for both bacterial and fungal infections.Recipient age older than 45 years,preoperative hyponatremia,intensive care unit stay longer than 9 d,postoperative bile leak and severe hyperglycemia were independent risk factors for postoperative bacterial infection.Massive red blood cells transfusion and postoperative bacterial infection may be related to postoperative fungal infection.CONCLUSION:Predictive risk factors for bacterial and fungal infections were indentified in current study.Pre-,intra-and post-operative factors can cause postoperative bacterial and fungal infections after LDLT.

Synchronous splenectomy and hepatectomy for patients with hepatocellular carcinoma and hypersplenism:A casecontrol study

AIM:To investigate whether the use of synchronoushepatectomy and splenectomy(HS)is more effective than hepatectomy alone(HA)for patients with hepatocellular carcinoma(HCC)and hypersplenism.METHODS:From January 2007 to March 2013,84consecutive patients with HCC and hypersplenism who underwent synchronous hepatectomy and splenectomy in our center were compared with 84 well-matched patients from a pool of 268 patients who underwent hepatectomy alone.The short-term and longterm outcomes of the two groups were analyzed and compared.RESULTS:The mean time to recurrence was 21.11±12.04 mo in the HS group and 11.23±8.73 mo in the HA group,and these values were significantly different(P=0.001).The 1-,3-,5-,and 7-year disease-free survival rates for the patients in the HS group and the HA group were 86.7%,70.9%,52.7%,and 45.9%and 88.1%,59.4%,43.3%,and 39.5%,respectively(P=0.008).Platelet and white blood cell counts in the HS group were significantly increased compared with the HA group one day,one week,one month and one year postoperatively(P<0.001).Splenectomy and micro-vascular invasion were significant independent prognostic factors for disease-free survival.Gender,tumor number,and recurrence were independent prognostic factors for overall survival.CONCLUSION:Synchronous hepatectomy and hepatectomy potentially improves disease-free survival rates and alleviates hypersplenism without increasing the surgical risks for patients with HCC and hypersplenism.

Current prophylactic strategies against hepatitis B virus recurrence after liver transplantation

Prophylactic strategies against hepatitis B virus(HBV) recurrence after liver transplantation(LT) are essential for patients with HBV-related disease.Before LT, lamivudine(LAM) was proposed to be down-graded from first-to second-line therapy.In contrast, adefovir dipivoxil(ADV) has been approved not only as first-line therapy but also as rescue therapy for patients with LAM resistance.Furthermore, combination of ADV and LAM may result in lower risk of ADV resistance than ADV monotherapy.Other new drugs such as entecavir, telbivudine and tenofovir, are probably candidates for the treatment of hepatitis-B-surface-antigen-positive patients awaiting LT.After LT, low-dose intramuscular hepatitis B immunoglobulin(HBIG), in combination with LAM, has been regarded as the most cost-effective regimen for the prevention of post-transplant HBV recurrence in recipients without pretransplant LAM resistance and rapidly accepted in many transplant centers.With the introduction of new antiviral drugs, new hepatitis B vaccine and its new adjuvants, post-transplant HBIG-free therapeutic regimens with new oral antiviral drug combinations or active HBV vaccination combined with adjuvants will be promising, particularly in those patients with low risk of HBV recurrence.

Combined Hangzhou criteria with neutrophillymphocyte ratio is superior to other criteria in selecting liver transplantation candidates with HBV-related hepatocellular carcinoma

BACKGROUND： The elevation of neutrophil-lymphocyte ratio （NLR） has adverse effects on the prognosis of patients with hepatocellular carcinoma （HCC） who have received liver transplantation （LT）. The Hangzhou criteria are set for selecting HCC patients for LT. The present study aimed to establish a set of new criteria combining the NLR and Hangzhou crite- ria for selecting HCC patients for LT.

Risk factors associated with early and late HAT after adult liver transplantation

AIM: To identify risk factors that might contribute to hepatic artery thrombosis (HAT) after liver transplantation (LT). METHODS: The perioperative and follow-up data of a total of 744 liver transplants, performed from February 1999 to July 2010, were retrospectively reviewed. HAT developed in 20 patients (2.7%). HAT was classified as early (occurring in fewer than 30 d post LT) or late (occurring more than 30 d post LT). Early HAT devel-oped in 14 patients (1.9%). Late HAT developed in 6 patients (0.8%). Risk factors associated with HAT were analysed using the chi(2) test for univariate analysis and logistic regression for multivariate analysis. RESULTS: Lack of ABO compatibility, recipient/donor weight ratio >= 1.15, complex arterial reconstruction, duration time of hepatic artery anastomosis > 80 min, duration time of operation > 10 h, dual grafts, number of units of blood received intraoperatively >= 7, number of units of fresh frozen plasma (FFP) received intraoperatively >= 6, postoperative blood transfusion and postoperative FFP use were significantly associated with early HAT in the univariate analysis (P < 0.1). After logistic regression, independent risk factors associated with early HAT were recipient/donor weight ratio >= 1.15 (OR = 4.499), duration of hepatic artery anastomosis > 80 min (OR = 5.429), number of units of blood received intraoperatively >= 7 (OR = 4.059) and postoperative blood transfusion (OR = 6.898). Graft type (whole/living-donor/split), duration of operation > 10 h, retransplantation, rejection reaction, recipients with diabetes preoperatively and recipients with a high level of blood glucose or diabetes postoperatively were significantly associated with late HAT in the univariate analysis (P < 0.1). After logistic regression, the independent risk factors associated with early HAT were duration of operation > 10 h (OR = 6.394), retransplantation (OR = 21.793) and rejection reactions (OR = 16.936). CONCLUSION: Early detection of these risk factors, strict surveillance protocols by Doppler ultrasound and prophylactic anticoagulation for recipients at risk might be determined prospectively. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

Transplantation vs resection for hepatocellular carcinoma with compensated liver function after downstaging therapy

AIM:Our study aimed to compare the results of liver transplantation (LT) and liver resection (LR) in patients with hepatocellular carcinoma (HCC) that met the Milan criteria after successful downstaging therapy. METHODS:From February 2004 to August 2010, a consecutive series of 102 patients were diagnosed with advanced-stage HCC that met the modified UCSF down-staging protocol inclusion criteria. All of the patients accepted various down-staging therapies. The types and numbers of treatments were tailored to each patient according to the tumor characteristics, location, liver function and response. After various downstaging therapies, 66 patients had tumor characteristics that met the Milan criteria; 31 patients accepted LT in our center, and 35 patients accepted LR. The baseline characteristics, down-staging protocols, postoperative complications, overall survival and tumor free survival rate, and tumor recurrence rate were compared between the two groups. Kaplan-Meier analyses were used to estimate the long-term overall survival and tumor-free survival rate. Meanwhile, a Cox proportional hazards model was used for the multivariate analyses of overall survival and disease-free survival rate. RESULTS:No significant difference was observed between the LT and LR groups with respect to the downstaging protocol, target tumor characteristics, and baseline patient characteristics. Fifteen patients suffered various complications after LT, and 8 patients had complications after LR. The overall complication rate for the LT group was 48.4%, which was significantly higher than the LR group (22.9%) (P = 0.031). The overall in-hospital mortality in hospital for the LT group was 12.9% vs 2.9% for the LR group (P = 0.172). The overall patient survival rates at 1-, 3and 5-years were 87.1%, 80.6% and 77.4%, respectively, after LT and 91.4%, 77.1% and 68.6%, respectively, after LR (P = 0.498). The overall 1-, 3and 5-year tumor recurrencefree rates were also comparable (P = 0.656). Poorer tumor differentiation (P = 0.041) and a higher postdownstage alpha-fetoprotein (AFP) level (> 400 ng/mL) (P = 0.015) were the two independent risk factors for tumor recurrence in the LT and LR patients who accepted successful down-staging therapy. CONCLUSION:Due to the higher postoperative morbidity and similar survival and tumor recurrence-free rates, LR might offer better or similar outcome over LT, but a larger number and further randomized studies may be needed in the future for drawing any positive conclusions.

Up-to-seven criteria for hepatocellular carcinoma liver transplantation:A single center analysis

AIM:To detect whether the up-to-seven should be used as inclusion criteria for liver transplantation for hepatocellular carcinoma.METHODS:Between April 2002 and July 2008,220hepatocellular carcinoma(HCC)patients who were diagnosed with HCC and underwent liver transplantation(LT)at our liver transplantation center were included.These patients were divided into three groups according to the characteristics of their tumors(tumor diameter,tumor number):the Milan criteria group(Group 1),the in up-to-seven group(Group 2)and the out up-toseven group(Group 3).Then,we compared long-term survival and tumor recurrence of these three groups.RESULTS:The baseline characteristics of transplant recipients were comparable among these three groups,except for the type of liver graft(deceased donor liver transplant or live donor liver transplantation).There were also no significant differences in the pre-operativeα-fetoprotein level.The 1-,3-,and 5-year overall survival and tumor-free survival rate for the Milan criteriagroup were 94.8%,91.4%,89.7%and 91.4%,86.2%,and 86.2%respectively;in the up-to-seven criteria group,these rates were 87.8%,77.8%,and 76.6%and 85.6%,75.6%,and 75.6%respectively(P<0.05).However,the advanced HCC patients’(in the group out of up-to-seven criteria)overall and tumor-free survival rates were much lower,at 75%,53.3%,and 50%and65.8%,42.5%,and 41.7%,respectively(P<0.01).CONCLUSION:Considering that patients in the up-toseven criteria group exhibited a considerable but lower survival rate compared with the Milan criteria group,the up-to-seven criteria should be used carefully and selectively.

Low immediate postoperative platelet count is associated with hepatic insufficiency after hepatectomy

AIM: To investigate the relationship between low immediate postoperative platelet count and perioperative outcome after liver resection in patients with hepatocellular carcinoma (HCC). METHODS: In a cohort of 565 consecutive hepatitis B-related HCC patients who underwent major liver resection, the characteristics and clinical outcomes after liver resection were compared between patients with immediate postoperative platelet count < 100 x 10(9)/L and patients with platelet count >= 100 x 10(9)/L. Risk factors for postoperative hepatic insufficiency were evaluated by multivariate analysis. RESULTS: Patients with a low immediate postoperative platelet count (< 100 x 10(9)/L) had more grade III-V. complications (20.5% vs 12.4%, P = 0.016), and higher rates of postoperative liver failure (6.8% vs 2.6%, P = 0.02), hepatic insufficiency (31.5% vs 21.2%, P < 0.001) and mortality (6.8% vs 0.5%, P < 0.001), compared to patients with a platelet count >= 100 x 10(9)/L. The alanine aminotransferase levels on postoperative days 3 and 5, and bilirubin on postoperative days 1, 3 and 5 were higher in patients with immediate postoperative low platelet count. Multivariate analysis revealed that immediate postoperative low platelet count, rather than preoperative low platelet count, was a significant independent risk factor for hepatic insufficiency. CONCLUSION: A low immediate postoperative platelet count is an independent risk factor for hepatic insufficiency. Platelets can mediate liver regeneration in the cirrhotic liver. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

Living donor liver transplantation does not increase tumor recurrence of hepatocellular carcinoma compared to deceased donor transplantation

AIM: to compare the recurrence-free survival (RFS) and overall survival (OS) of hepatitis B virus (HBV)-positive hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT). METHODS: We retrospectively collected clinical data from 408 liver cancer patients from February 1999 to September 2012. We used the chi-squared test or Fisher's exact test to analyze the characteristics of LDLT and DDLT. Kaplan-Meier analysis was used to compare the RFS and OS in HCC. RESULTS: Three hundred sixty HBV-positive patients (276 DDLT and 84 LDLT) were included in this study. The mean follow-up time was 27.1 mo (range 1.1-130.8 mo). One hundred eighty-five (51.2%) patients died during follow-up. The 1-, 3-, and 5-year RFS rates for LDLT were 85.2%, 55.7%, and 52.9%, respectively; for DDLT, the RFS rates were 73.2%, 49.1%, and 45.3% (P = 0.115). The OS rates were similar between the LDLT and DDLT recipients, with 1-, 3-, and 5-year survival rates of 81.8%, 49.5%, and 43.0% vs 69.5%, 43.0%, and 38.3%, respectively (P = 0.30). The outcomes of HCC according to the Milan criteria after LDLT and DDLT were not significantly different (for LDLT: 1-, 3-, and 5-year RFS: 94.7%, 78.7%, and 78.7% vs 89.2%, 77.5%, and 74.5%, P = 0.50; for DDLT: 86.1%, 68.8%, and 68.8% vs 80.5%, 62.2%, and 59.8% P = 0.53). CONCLUSION: The outcomes of LDLT for HCC are not worse compared to the outcomes of DDLT. LDLT does not increase tumor recurrence of HCC compared to DDLT. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

Nuclear factor-KB decoy oligodeoxynucleotides attenuates ischemia/reperfusion injury in rat liver graft

AIM： To evaluate the protective effect of NF-kB decoy oligodeoxynucleotides （ODNs） on ischemia/reperfusion （I/R） injury in rat liver graft. METHODS： Orthotopic syngeneic rat liver transplantation was performed with 3 h of cold preservation of liver graft in University of Wisconsin solution containing phosphorothioated double-stranded NF-kB decoy ODNs or scrambled ODNs. NF-kB decoy ODNs or scrambled ODNs were injected intravenously into donor and recipient rats 6 and 1 h before operation, respectively. Recipients were killed 0 to 16 h after liver graft reperfusion. NF-kB activity in the liver graft was analyzed by electrophoretic mobility shift assay （EMSA）. Hepatic mRNA expression of TNF-α, IFN-γ and intercellular adhesion molecule-1 （ICAM-1） were determined by semiquantitative RT-PCR. Serum levels of TNF-α and IFN-γ were measured by enzyme-linked immunosorbent assays （ELISA）. Serum level of alanine transaminase （ALT） was measured using a diagnostic kit. Liver graft myeloperoxidase （MPO） content was assessed. RESULTS： NF-kB activation in liver graft was induced in a time-dependent manner, and NF-kB remained activated for 16 h after graft reperfusion. NF-kB activation in liver graft was significant at 2 to 8 h and slightly decreased at 16 h after graft reperfusion. Administration of NF-kB decoy ODNs significantly suppressed NF-kB activation as well as mRNA expression of TNF-α, IFN-γ, and ICAM-1 in the liver graft. The hepatic NF-kB DNA binding activity [presented as integral optical density （IOD） value] in the NF-kB decoy ODNs treatment group rat was significantly lower than that of the I/R group rat （2.16±0.78 vs 36.78 ±6.35 and 3.06±0.84 vs 47.62± 8.71 for IOD value after 4 and 8 h of reperfusion, respectively, P〈0.001）. The hepatic mRNA expression level of TNF-α, IFN-γ and ICAM-1 rpresented as percent of β-actin mRNA （%）] in the NF-kB decoy ODNs treatment group rat was significantly lower than that of the I/R group rat （8.31 ±3.48 vs 46.37±10.65 and 7.46± 3.72 vs 74.82±12.25 for hepatic TNF-α mRNA, 5.58±2.16 vs 50.46±9.35 and 6.47±2.53 vs 69.72±13.41 for hepatic IFN-γ mRNA, 6.79 ±2.83 vs 46.23±8.74 and 5.28±2.46 vs 67.44±10.12 for hepatic ICAM-1 mRNA expression after 4 and 8 h of reperfusion, respectively, P〈0.001）. Administration of NF-kB decoy ODNs almost completely abolished the increase of serum level of TNF-α and IFN-γ induced by hepatic ischemia/reperfusion, the serum level （pg/mL） of TNF-α and in the NF-kB decoy ODNs treatment group rat was significantly lower than that of the I/R group rat （42.7±13.6 vs 176.7±15.8 and 48.4±15.1 vs 216.8±17.6 for TNF-α level, 31.5±12.1 vs 102.1±14.5 and 40.2±13.5 vs 118.6±16.7 for IFN-γ level after 4 and 8 h of reperfusion, respectively, P〈0.001）. Liver graft neutrophil recruitment indicated by MPO content and hepatocellular injury indicated by serum ALT level were significantly reduced by NF-kB decoy ODNs, the hepatic MPO content （A655） and serum ALT level （IU/L） in the NF-kB decoy ODNs treatment group rat was significantly lower than that of the I/R group rat （0.17±0.07 vs 1.12±0.25 and 0.46±0.17 vs 1.46±0.32 for hepatic MPO content, 71.7±33.2 vs 286.1±49.6 and 84.3±39.7 vs 467.8±62.3 for ALT level after 4 and 8 h of reperfusion, respectively, P〈0.001）. CONCLUSION： The data suggest that NF-kB decoy ODNs protects against I/R injury in liver graft by suppressing NF-kB activation and subsequent expression of proinflammatory mediators.