Management of and LDLT Outcomes in ultra-high-risk patients

Kenneth Siu Ho Chok 한국간담췌외과학회 2017 한국간담췌외과학회 학술대회지 Vol.2017 No.3

Major Hepatectomy for Hepatocellular Carcinoma Patients with Poor Indocyanine Green Clearance

( Kenneth Siu Ho Chok ),( Kin-pan Au ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: To review whether major hepatectomies were worthwhile for hepatocellular carcinoma (HCC) patients with poor indocyanine green (ICG) clearance i.e. ICG retention at 15 minutes (ICG15) more than 14.0% Methods: A retrospective analysis of 627 HCC patients who underwent major hepatectomy from January 2000 to December 2015. Results: 470 (75.0%) patients had ICG15 < =14.0%, while 96 (15.3%), 30 (4.8%) and 31 (4.9%) patients had ICG15 of 14.1-18.0%, 18.1-22.0% and >22.0% respectively. Patients with less satisfactory ICG15 had comparably higher bilirubin (10 (8-14) vs. 11 (9-16) vs. 15 (9-22) vs. 15 (10-22) μmol/L, p<0.001) and lower albumin (41 (39-43) vs. 39 (36-41) vs. 37 (35-41) vs. 37 (34-41) g/L, p<0.001), but the clinical values were essentially normal. Their international normalized ratio (INR) were slightly more prolonged (1.0 (1.0-1.1) vs. 1.1 (1.0-1.1) vs. 1.1 (1.0-1.1) vs. 1.1 (1.0-1.2), p< 0.001), while their platelet counts were comparable (197 (160-253) vs. 171 (138-236) vs. 218 (174-246) vs. 187 (143-247) x10^9/L, p=0.18). Patients with ICG15 ranged 18.1-22.0 and >22.0% had more blood loss (0.8 (0.5-1.5) vs. 0.9 (0.5-1.5) vs. 1.5 (0.6-2.6) vs. 1.5 (0.5-2.5) litre, p=0.009). Their operating time and hospital stay were similar. Patients with very poor ICG clearance i.e. >22.0% did not suffer more post-hepatectomy liver failure (3.6% vs. 6.3% vs. 6.7% vs. 3.2%, p=0.29) or in-hospital mortality (2.8% vs. 6.3% vs. 6.7% vs. 3.2%, p=0.10). Their overall survivals were comparable (median 1.94+/-0.71 vs. 4.34+/-1.27 vs. 2.15+/-0.83 vs. 3.19+/-1.48 yrs, p=0.44). Conclusions: In selected patients, very poor ICG clearance did not preclude major hepatectomy. Given normal liver function test, good clotting profile and platelet counts, these patients could be operated with minimal mortality and satisfactory long term outcomes.

Anatomical limits in living donor liver transplantation

Kin Pan Au,Kenneth Siu Ho Chok 대한이식학회 2022 Korean Journal of Transplantation Vol.36 No.3

We review the anatomical limits of living donor liver transplantation. Graft size is the fundamental challenge in partial liver transplantation. Insufficient graft size leads to small-for-size syndrome, graft failure, and graft loss. However, smaller grafts can be used safely with surgical techniques to optimize outflow and modulate inflow, thereby minimizing portal hyperperfusion. Meanwhile, anatomical variations are common in the vascular and biliary systems. These variants pose additional challenges for vascular and biliary reconstruction. Recognition and appropriate management of these variants ensure donor safety and reduce recipient morbidity. The ultimate principle of partial liver transplantation is to ensure a sufficient graft volume with unimpeded outflow and reconstructable vascular and biliary systems. On this basis, the anatomical limits of living donor liver transplantation can be safely expanded.

Living Donor Liver Transplant Confers Better Survival for Elderly Recipients

( Chu Kevin Ka-wan ),( Chok Kenneth Siu-ho ),( Fung James Yan-yue ),( Chan Albert Chi-yan ),( Lo Chung Mau ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: Increasing elderly patients are undergoing liver transplant as well as the relative percentage of elderly population. However, the perceived poor outcomes in the elderly prohibits the acceptance of living donor liver transplant in many centres. We reviewed current status of liver transplant in our centre and analyzed factors predicting survival outcome in elderly liver transplant recipients. Methods: Consecutive liver transplants for elderlies who reached age 65 performed between 2001 and 2016 were reviewed. The overall survival were compared between the deceased donor liver transplant (DDLT) and the living donor liver transplant (LDLT) groups. Results: DDLT and LDLT groups consisted of 24 and 17 recipients respectively. The overall 1-year and 3-year survival rates for the elderlies (n=41) were 87%, 78% respectively. LDLT recipients had better survival compared with DDLT, 94% vs 83% for 1-year and 94% vs 67% for 3-year, p=0.036. Univariate analysis was performed and identified predictive factors including pre-operative ICU stay (relative risk 3.74, 95% confidence interval 1.06-13.14, p=0.039), pre-operative hepatorenal syndrome (relative risk 6.01, 95% confidence interval 1.67-21.68, p=0.006) and mode of graft donation - LDLT (relative risk 0.09, 95% confidence interval 0.01-0.86, p=0.036). Long cold ischaemic time also had a negative correlation with survival (relative risk 4.30, 95% confidence interval 0.81-22.90, p=0.087). In multi multivariate analysis, LDLT (hazard ratio 0.11, 95% confidence interval 0.01-0.94, p=0.043) and pre-operative ICU stay (hazard ratio 5.60, 95% confidence interval 1.30-24.03, p=0.021) were independent predictive factors for survival. Conclusions: Good survival outcomes was achieved in selected elderly liver transplant recipients. Elderly recipients with living donors had better survival outcomes in contrast to those with deceased donors and LDLT was an independent protective factor for long term survival. Pre-operative ICU status was also an independent predictive of poorer long term survival.

Defining Optimal Surgical Treatment for Recurrent Hepatocellular Carcinoma: A Propensity Score Matched Analysis

( Ka Wing Ma ),( Kenneth Siu Ho Chok ),( Albert Chi Yan Chan ),( James Yan Yue Fung ),( Chung Mau Lo ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: Salvage liver transplantation (sLT) and repeated resection (RR) are effective treatment for recurrent hepatocellular carcinoma (HCC), comparison of the oncological outcomes between these two modalities were scarce. Methods: Consecutive patients admitted for either sLT or RR for recurrent HCC were recruited. All patients in the present series received either prior hepatectomy, ablative therapy or both before RR and sLT. Paedatric patients and patients treated by non-curative approach were excluded. Patient demographic, perioperative and outcome data were analyzed. Survival analysis was performed after propensity score matching. Results: There were 277 eligible patients recruited, 67 and 210 of them underwent sLT and RR respectively. Significant difference in preoperative haemoglobin, albumin, hepatitis B carrier status, MELD score, and tumor number were found (all P<0.001) between sLT and RR group. Multivariate analysis revealed that type of treatment (P=0.002, OR=2.13 95%CI 1.2-3.2), lapse time from last curative treatment (P=0.022, OR=0.994 95%CI 0.988-0.999), alpha fetal protein (AFP) (P=0.01 OR=1.00 95%CI 1.00-1.00) and tumor number (P<0.001, OR=1.23 95%CI 1.14-1.32) were independent factors associated with overall survival. After 1:3 PS matching, there were 36 sLT and 108 RS patients for comparison. The median age, MELD, AFP, tumor size and umber of the matched population were 57, 7.5, 16U/ml, 2.5cm and 1 respectively. There was no difference in the hospital mortality and complication rate (Clavien IIIa or above) between the groups, while the blood loss (P<0.001), operation time (P<0.001) and hospital stay (P=0.002) were significantly more in the sLT group. Patients in sLT group had significantly longer disease free (140 vs 49 months, P=0.031) and overall survival (176 vs 55.3 months, P=0.026). Conclusions: Salvage LT is superior to repeated resection for treatment of recurrent HCC and is associated with more than two fold increase in long term survival.

Expanding Indications for Liver Transplant: Tumor and Patient Factors

( Kevin Ka-wan Chu ),( Kelly Hiu-ching Wong ),( Kenneth Siu-ho Chok ) 대한간학회 2021 Gut and Liver Vol.15 No.1

During the past few decades, liver transplant has developed from a high-mortality procedure to an almost routine procedure with good survival outcomes. The development of living donor liver transplant has increased the availability of liver grafts, and the scope of indications for liver transplant has been expanding ever since. The aim of this review is to provide an overview of such an expansion of scope. Various criteria have been proposed to expand the eligibility of patients with hepatocellular carcinoma exceeding the Milan criteria for liver transplant. Furthermore, liver transplant is increasingly performed as a treatment modality for cholangiocarcinoma, neuroendocrine liver metastasis and colorectal liver metastasis. The number of elderly patients receiving liver transplant is on the rise. Combined organ transplantation has also been adopted to treat patients with multiple organ failure. Going forward, further development of preoperative noninvasive predictors in tumor, patient and even donor factors is needed to identify patients at risk of poor outcomes and hence optimize patient management. (Gut Liver 2021;15:19-30)