The Evolving Landscape of Liver Cirrhosis Management, 2019
Liver transplantation (LT) is the only curative treatment that can increase the chances of long-t... more Liver transplantation (LT) is the only curative treatment that can increase the chances of long-term survival in patients with end-stage liver disease including liver cirrhosis (LC), acute liver failure, or advanced hepatocellular carcinoma (HCC). Especially in patients with LC and HCC, LT is an ideal treatment, allowing not only resection of the HCC, but also provision of normal liver in place of damaged liver that would promote multicentric carcinogenesis. LT includes deceased donor LT and living donor LT. In this chapter, we first introduce current status and results of LT, and then discuss recent issues in LT for decompensated liver cirrhosis.
A 57-year-old man with a history of hepatitis B virus infection was referred to our hospital for ... more A 57-year-old man with a history of hepatitis B virus infection was referred to our hospital for living-donor liver transplantation (LDLT). Five years earlier, right lobectomy had been performed for solitary hepatocellular carcinoma (HCC) with bile duct tumor thrombus in segments 5 and 6 in the liver. Two years later, transarterial chemoembolization and radiofrequency ablation were performed for recurrent HCC. Two years after those local therapies, another recurrent HCC was treated with transhepatic arterial infusion chemotherapy with cisplatin and conventional radiation therapy (RT) with 60 Gy in 20 fractions, because the tumor was contiguous to the trunk of the portal vein. After the completion of RT, symptoms due to liver failure and severe infection caused by multiple liver abscesses developed despite the administration of antibiotics and percutaneous transhepatic cholangiodrainage. Therefore, LDLT was performed with the use of a right lobe graft donated by his wife. Vascular an...
Background: Portal vein embolization (PVE) is considered to improve the safety of major hepatecto... more Background: Portal vein embolization (PVE) is considered to improve the safety of major hepatectomy. Various conditions might affect remnant liver hypertrophy after PVE. The aim of the present study was to clarify the factors that affect remnant liver hypertrophy and to establish a prediction formula for the hypertrophy ratio. Methods: Fifty-nine patients who underwent preoperative PVE for cholangiocarcinoma (39 patients), metastatic carcinoma (10 patients), hepatocellular carcinoma (8 patients), and other diseases (2 patients) were enrolled in this study. For the prediction of the hypertrophy ratio, a formula with stepwise multiple regression analysis was set up. The following parameters were used: age, gender, future liver remnant ratio to total liver (FLR%), plasma disappearance rate of indocyanine green (ICGK), platelet count, prothrombin activity, serum albumin, serum total bilirubin at the time of PVE and the maximum value before PVE (Max Bil), as well as a history of cholangi...
Background. Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based, program of ca... more Background. Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based, program of care developed to minimize the response to surgical stress, associated with reduced perioperative morbidity and hospital stay. This study presents the specific ERAS Society recommendations for liver transplantation (LT) based on the best available evidence and on expert consensus Methods. PubMed and ClinicalTrials.gov were searched in April 2019 for published and ongoing randomized clinical trials on LT in the last 15 y. Studies were selected by 5 independent reviewers and were eligible if focusing on each validated ERAS item in the area of adult LT. An e-Delphi method was used with an extended interdisciplinary panel of experts to validate the final recommendations. Results. Forty-three articles were included in the systematic review. A consensus was reached among experts after the second round. Patients should be screened for malnutrition and treated whenever possible. Prophylactic nasog...
Background : The bare area, which lies between the right liver and diaphragm, should be dissected... more Background : The bare area, which lies between the right liver and diaphragm, should be dissected to mobilize the right liver. The bare area was reportedly formed by direct adhesion between the liver and diaphragm, meaning that the bare area lacked serosal components. This study aimed to analyze the structure of the bare area by an integrated study of surgical and laparoscopic images and pathological studies and describe surgical procedures focusing on the multilayered structure. Methods : Surgical specimens of hepatectomy were analyzed histologically to evaluate the macroscopic structure of the bare area. Laparoscopic images and cadaver anatomy of the bare area were also examined, changing the dissection layers of the bare area. Results : The bare area comprised a multilayered structure that resulted in fusions in the hepatic development among the parietal peritoneum (peritoneum of the diaphragm part) and the visceral peritoneum (liver serosa). The multilayered structure of the bar...
Objective: Visceral adiposity, defined as a high visceral-to-subcutaneous adipose tissue area rat... more Objective: Visceral adiposity, defined as a high visceral-to-subcutaneous adipose tissue area ratio (VSR), has been shown to be associated with poor outcomes in several cancers. However, in the surgical field, the significance of visceral adiposity remains controversial. The present study investigated the impact of visceral adiposity as well as sarcopenic factors (low muscularity) on outcomes in patients undergoing hepatectomy for hepatocellular carcinoma (HCC). Patients and Methods: This retrospective study analyzed data from 606 patients undergoing hepatectomy for HCC at our institution between April 2005 and March 2016. Using preoperative plain computed tomography imaging at the level of the third lumbar vertebra, visceral adiposity, skeletal muscle mass, and muscle quality were evaluated by the VSR, skeletal muscle mass index (SMI), and intramuscular adipose tissue content (IMAC), respectively. The impact of these parameters on outcomes after hepatectomy for HCC was analyzed. Re...
Prognosticating outcomes in liver transplant (LT) for hepatocellular carcinoma (HCC) continues to... more Prognosticating outcomes in liver transplant (LT) for hepatocellular carcinoma (HCC) continues to challenge the field. Although Milan Criteria (MC) generalized the practice of LT for HCC and improved outcomes, its predictive character has degraded with increasing candidate and oncological heterogeneity. We sought to validate and recalibrate a previously developed, preoperatively calculated, continuous risk score, the Hazard Associated with Liver Transplantation for Hepatocellular Carcinoma (HALTHCC), in an international cohort. From 2002 to 2014, 4,089 patients (both MC in and out [25.2%]) across 16 centers in North America, Europe, and Asia were included. A continuous risk score using pre‐LT levels of alpha‐fetoprotein, Model for End‐Stage Liver Disease Sodium score, and tumor burden score was recalibrated among a randomly selected cohort (n = 1,021) and validated in the remainder (n = 3,068). This study demonstrated significant heterogeneity by site and year, reflecting practice t...
The Evolving Landscape of Liver Cirrhosis Management, 2019
Liver transplantation (LT) is the only curative treatment that can increase the chances of long-t... more Liver transplantation (LT) is the only curative treatment that can increase the chances of long-term survival in patients with end-stage liver disease including liver cirrhosis (LC), acute liver failure, or advanced hepatocellular carcinoma (HCC). Especially in patients with LC and HCC, LT is an ideal treatment, allowing not only resection of the HCC, but also provision of normal liver in place of damaged liver that would promote multicentric carcinogenesis. LT includes deceased donor LT and living donor LT. In this chapter, we first introduce current status and results of LT, and then discuss recent issues in LT for decompensated liver cirrhosis.
A 57-year-old man with a history of hepatitis B virus infection was referred to our hospital for ... more A 57-year-old man with a history of hepatitis B virus infection was referred to our hospital for living-donor liver transplantation (LDLT). Five years earlier, right lobectomy had been performed for solitary hepatocellular carcinoma (HCC) with bile duct tumor thrombus in segments 5 and 6 in the liver. Two years later, transarterial chemoembolization and radiofrequency ablation were performed for recurrent HCC. Two years after those local therapies, another recurrent HCC was treated with transhepatic arterial infusion chemotherapy with cisplatin and conventional radiation therapy (RT) with 60 Gy in 20 fractions, because the tumor was contiguous to the trunk of the portal vein. After the completion of RT, symptoms due to liver failure and severe infection caused by multiple liver abscesses developed despite the administration of antibiotics and percutaneous transhepatic cholangiodrainage. Therefore, LDLT was performed with the use of a right lobe graft donated by his wife. Vascular an...
Background: Portal vein embolization (PVE) is considered to improve the safety of major hepatecto... more Background: Portal vein embolization (PVE) is considered to improve the safety of major hepatectomy. Various conditions might affect remnant liver hypertrophy after PVE. The aim of the present study was to clarify the factors that affect remnant liver hypertrophy and to establish a prediction formula for the hypertrophy ratio. Methods: Fifty-nine patients who underwent preoperative PVE for cholangiocarcinoma (39 patients), metastatic carcinoma (10 patients), hepatocellular carcinoma (8 patients), and other diseases (2 patients) were enrolled in this study. For the prediction of the hypertrophy ratio, a formula with stepwise multiple regression analysis was set up. The following parameters were used: age, gender, future liver remnant ratio to total liver (FLR%), plasma disappearance rate of indocyanine green (ICGK), platelet count, prothrombin activity, serum albumin, serum total bilirubin at the time of PVE and the maximum value before PVE (Max Bil), as well as a history of cholangi...
Background. Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based, program of ca... more Background. Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based, program of care developed to minimize the response to surgical stress, associated with reduced perioperative morbidity and hospital stay. This study presents the specific ERAS Society recommendations for liver transplantation (LT) based on the best available evidence and on expert consensus Methods. PubMed and ClinicalTrials.gov were searched in April 2019 for published and ongoing randomized clinical trials on LT in the last 15 y. Studies were selected by 5 independent reviewers and were eligible if focusing on each validated ERAS item in the area of adult LT. An e-Delphi method was used with an extended interdisciplinary panel of experts to validate the final recommendations. Results. Forty-three articles were included in the systematic review. A consensus was reached among experts after the second round. Patients should be screened for malnutrition and treated whenever possible. Prophylactic nasog...
Background : The bare area, which lies between the right liver and diaphragm, should be dissected... more Background : The bare area, which lies between the right liver and diaphragm, should be dissected to mobilize the right liver. The bare area was reportedly formed by direct adhesion between the liver and diaphragm, meaning that the bare area lacked serosal components. This study aimed to analyze the structure of the bare area by an integrated study of surgical and laparoscopic images and pathological studies and describe surgical procedures focusing on the multilayered structure. Methods : Surgical specimens of hepatectomy were analyzed histologically to evaluate the macroscopic structure of the bare area. Laparoscopic images and cadaver anatomy of the bare area were also examined, changing the dissection layers of the bare area. Results : The bare area comprised a multilayered structure that resulted in fusions in the hepatic development among the parietal peritoneum (peritoneum of the diaphragm part) and the visceral peritoneum (liver serosa). The multilayered structure of the bar...
Objective: Visceral adiposity, defined as a high visceral-to-subcutaneous adipose tissue area rat... more Objective: Visceral adiposity, defined as a high visceral-to-subcutaneous adipose tissue area ratio (VSR), has been shown to be associated with poor outcomes in several cancers. However, in the surgical field, the significance of visceral adiposity remains controversial. The present study investigated the impact of visceral adiposity as well as sarcopenic factors (low muscularity) on outcomes in patients undergoing hepatectomy for hepatocellular carcinoma (HCC). Patients and Methods: This retrospective study analyzed data from 606 patients undergoing hepatectomy for HCC at our institution between April 2005 and March 2016. Using preoperative plain computed tomography imaging at the level of the third lumbar vertebra, visceral adiposity, skeletal muscle mass, and muscle quality were evaluated by the VSR, skeletal muscle mass index (SMI), and intramuscular adipose tissue content (IMAC), respectively. The impact of these parameters on outcomes after hepatectomy for HCC was analyzed. Re...
Prognosticating outcomes in liver transplant (LT) for hepatocellular carcinoma (HCC) continues to... more Prognosticating outcomes in liver transplant (LT) for hepatocellular carcinoma (HCC) continues to challenge the field. Although Milan Criteria (MC) generalized the practice of LT for HCC and improved outcomes, its predictive character has degraded with increasing candidate and oncological heterogeneity. We sought to validate and recalibrate a previously developed, preoperatively calculated, continuous risk score, the Hazard Associated with Liver Transplantation for Hepatocellular Carcinoma (HALTHCC), in an international cohort. From 2002 to 2014, 4,089 patients (both MC in and out [25.2%]) across 16 centers in North America, Europe, and Asia were included. A continuous risk score using pre‐LT levels of alpha‐fetoprotein, Model for End‐Stage Liver Disease Sodium score, and tumor burden score was recalibrated among a randomly selected cohort (n = 1,021) and validated in the remainder (n = 3,068). This study demonstrated significant heterogeneity by site and year, reflecting practice t...
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Papers by Toshimi Kaido