Modern liver surgeon must be equipped with excellent theoretical and clinical skills to perform a... more Modern liver surgeon must be equipped with excellent theoretical and clinical skills to perform a perfect liver resection. A particular and growing relevance is devoted to parenchyma sparing liver surgery (PSS). Indeed, reducing the sacrifice of functioning parenchyma is one of the keys of a successful surgery, once oncological issues are properly addressed. Intraoperative ultrasound together with oncological and anatomical new insights have enhanced the possibility to offer PSS even in advanced disease usually afforded with major resections or staged procedures or even considered unresectable. These complex hepatectomies are mainly performed with open surgery, while major or staged procedures could be faced with minimal access liver surgery (MALS): that is generating a potential conflict between open PSS and MALS major hepatectomies. An overall evaluation of oncological radicality, safety, salvageability, and quality of life suggest to prioritize PSS, which is always minimal invasive liver surgery in a hepatic-centered perspective, while MALS is not.
Patients with hydatid cysts in the liver used to present a therapeutic challenge. Although surgic... more Patients with hydatid cysts in the liver used to present a therapeutic challenge. Although surgical techniques have improved, considerable controversy still exists regarding the most effective operative technique. The main principle of the surgery is to eradicate the parasite and prevent intraoperative spillage of cyst contents avoiding peritoneal spread. Pericystectomy provides a radical treatment removing the whole cyst "en bloc" including the adventitia without resection of healthy liver tissue. Preoperative Treatment Albendazol orally 10-14mg/kg/day in two doses administered 2-4weeks before and after surgery.
ocal nodular fatty infiltration of the liver is a pseudotumor visualized as a highly echoic lesio... more ocal nodular fatty infiltration of the liver is a pseudotumor visualized as a highly echoic lesion on sonography. On computed tomography (CT), focal nodular fatty infiltration is generally characterized by a low-density area with no mass effect. 1 Although focal nodular fatty infiltration must be differentiated from primary liver cancer, a metastatic liver tumor, or hepatic hemangioma, this can be difficult with CT or sonography alone. When differential diagnosis is difficult from imaging investigations alone, biopsy proof of the tumor is necessary before therapy is commenced. The appearance of numerous small multifocal nodular fatty infiltrations in both hepatic lobes may mimic that of metastatic liver disease, leading to incorrect therapy. Particularly if the patient has had malignant disease in the past, multifocal nodular fatty infiltrations may be misdiagnosed, and incorrect therapy may be performed without adequate examination or differential diagnosis of the primary lesion. Although magnetic resonance imaging (MRI) and fine-needle biopsy are reportedly useful in diagnosing focal fatty infiltration of the liver, 2-4 the value of enhanced sonography has not been reported in this situation. We encountered a case of multifocal nodular fatty infiltration in which findings of the late parenchymal phase of enhanced sonography with Levovist (SH U 508A; Schering AG, Berlin, Germany) were useful in ruling out malignancy.
The Editors welcome topical correspondence from readers relating to articles published in the Jou... more The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses can be sent electronically via the BJS website (www.bjs.co.uk) or by post. All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Letters submitted by post should be typed on A4-sized paper in double spacing and should be accompanied by a disk.
Antecedentes: Los tumores benignos solidos del higado (TBSH) constituyen una patologia poco comun... more Antecedentes: Los tumores benignos solidos del higado (TBSH) constituyen una patologia poco comun. La mayoria de ellos son asintomaticos y de diagnostico accidental. Un pequeno numero de pacientes sufre complicaciones entre las que se encuentran la hemorragia y la transformacion maligna. Objetivo: Describir las complicaciones observadas en los pacientes operados por TBSH y analizar la conducta terapeutica y la evolucion postoperatoria de este grupo de enfermos. Diseno: Estudio clinico restrospectivo. Poblacion: De los 99 pacientes portadores de TBSH que fueron operados, 18 (18,1 por ciento) estaban complicados. En este grupo se incluyen: 6/49 (12,2 por ciento) hemangiomas, 8/21 (38,1 por ciento) adenomas, 2/16 (12,5 por ciento) hiperplasias nodulares focales, 1 hamartoma y 1 pseudotumor inflamatorio. La complicacion mas frecuente fue la hemorragica (66,6 por ciento) en 3 casos por biopsias preoperatorias. Todos los pacientes con adenomas asociados a hemorragia presentaban antecedentes de ingesta de anticonceptivos orales. Ademas se describen 3 transformaciones malignas, 1 necrosis infectada, 1 sindrome de Kasabach Merrit y 1 sindrome de Budd Chiari. Metodo: Con excepcion de un caso, todos los pacientes fueron resecados requiriendo de trasplante hepatico en 2 oportunidades. El paciente no resecado fue sometido a laparotomia exploradora y biopsia por un hemangioma con comportamiento agresivo. El seguimiento se realizo mediante evaluacion clinica y estudios por imagenes. Resultados: La morbilidad postoperatoria en los TBSH complicados fue de 4/18 (22,2 por ciento). No hubo mortalidad postoperatoria en este grupo, siendo la global de la serie de 1 por ciento (1 hemorragia cerebral por ruptura de una malformacion vascular). El seguimiento alcanzo un promedio de 3,2 anos (rango 1 mes-12 anos). Todos los pacientes resecados se hallan libres del tumor. El paciente con el hemangioma invasivo fallecio a los 26 meses del postoperatorio. Conclusiones: 1. La ingesta de anticonceptivos orales podria ser un factor importante en la paricion de complicaciones hemorragicas en pacientes con adenomas hepaticos. 2. La malignizacion es una complicacion a tener en cuenta en los adenomas y las hiperplasias nodulares focales. 3. Deben sospecharse patologias cerebrales asociadas en pacientes con tumores hepaticos benignos. 4. Debe evitarse la biopsia hepatica que no modifica la conducta terapeutica, ya que puede precipitar una complicacion...(AU)
Background: Although there is a worldwide need to expand the pool of available liver grafts, cada... more Background: Although there is a worldwide need to expand the pool of available liver grafts, cadaveric livers with severe steatosis (Ͼ60%) are discarded for orthotopic liver transplantation (OLT) by most centers. Methods: We analyzed patients receiving liver grafts with severe steatosis between January 2002 and September 2006. These patients were matched 1:2 with control patients without severe steatosis according to status the waiting list, recipient age, recipient body mass index (BMI), and model for end-stage liver disease (MELD) score. Primary end points were the incidence of primary graft nonfunction (PNF), and graft and patient survival. Secondary end points included primary graft dysfunction (PDF), the incidence of postoperative complications, and histologic assessment of steatosis in follow-up biopsies. We also conducted a survey on the use of grafts with severe steatosis among leading European liver transplant centers. Results: During the study period, 62 patients dropped out of the waiting list and 45 of them died due to progression of disease. Of 118 patients who received transplants 20 (17%) received a graft with severe steatosis during this period. The median degree of total liver steatosis was 90% (R ϭ 65%-100%) for the steatotic group. The steatotic (n ϭ 20) and matched control group (n ϭ 40) were comparable in terms of recipient age, BMI, MELD score, and cold ischemia time. The steatotic group had a significantly higher rate of PDF and/or renal failure. Although the median intensive care unit (ICU) and hospital stay were not significantly different between both groups, the proportion of patients with long-term ICU (Ն21 days) and hospital (Ն40 days) stay was significantly higher for patients with a severely steatotic graft. Sixty-day mortality (5% vs. 5%) and 3-year patient survival rate (83% vs. 84%) were comparable between the control and severe steatosis group. Postoperative histo-logic assessment demonstrated that the median total amount of liver steatosis decreased significantly (median: 90% to 15%, P Ͻ 0.001). Our survey showed that all but one of the European centers currently reject liver grafts with severe steatosis for any recipient. Conclusion: Due to the urgent need of liver grafts, severely steatotic grafts should be no longer discarded for OLT. Maximal effort must be spent when dealing with these high-risk organs but the use of severely steatotic grafts may save the lives of many patients who would die on the waiting list.
BackgroundA key tenet of clinical management of patients post liver transplantation (LT) is the p... more BackgroundA key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding.MethodsSystematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding (CRD42021244288).ResultsOf the 2478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post‐LT, yet it did not increase the risk of bleeding.ConclusionsBased on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT.
Background & Aims Patients with hepatocellular carcinoma (HCC) are selected for liver transpl... more Background & Aims Patients with hepatocellular carcinoma (HCC) are selected for liver transplantation (LT) based on pre-LT imaging ± alpha-foetoprotein (AFP) level, but discrepancies between pre-LT tumour assessment and explant are frequent. Our aim was to design an explant-based recurrence risk reassessment score to refine prediction of recurrence after LT and provide a framework to guide post-LT management. Methods Adult patients who underwent transplantation between 2000 and 2018 for HCC in 47 centres were included. A prediction model for recurrence was developed using competing-risk regression analysis in a European training cohort (TC; n = 1,359) and tested in a Latin American validation cohort (VC; n=1,085). Results In the TC, 76.4% of patients with HCC met the Milan criteria, and 89.9% had an AFP score of ≤2 points. The recurrence risk reassessment (R3)-AFP model was designed based on variables independently associated with recurrence in the TC (with associated weights): ≥4 nodules (sub-distribution of hazard ratio [SHR] = 1.88, 1 point), size of largest nodule (3–6 cm: SHR = 1.83, 1 point; >6 cm: SHR = 5.82, 5 points), presence of microvascular invasion (MVI; SHR = 2.69, 2 points), nuclear grade >II (SHR = 1.20, 1 point), and last pre-LT AFP value (101–1,000 ng/ml: SHR = 1.57, 1 point; >1,000 ng/ml: SHR = 2.83, 2 points). Wolber’s c-index was 0.76 (95% CI 0.72–0.80), significantly superior to an R3 model without AFP (0.75; 95% CI 0.72–0.79; p = 0.01). Four 5-year recurrence risk categories were identified: very low (score = 0; 5.5%), low (1–2 points; 15.1%), high (3–6 points; 39.1%), and very high (>6 points; 73.9%). The R3-AFP score performed well in the VC (Wolber’s c-index of 0.78; 95% CI 0.73–0.83). Conclusions The R3 score including the last pre-LT AFP value (R3-AFP score) provides a user-friendly, standardised framework to design post-LT surveillance strategies, protocols, or adjuvant therapy trials for HCC not limited to the Milan criteria. Clinical Trials Registration NCT03775863. Lay summary Considering discrepancies between pre-LT tumour assessment and explant are frequent, reassessing the risk of recurrence after LT is critical to further refine the management of patients with HCC. In a large and international cohort of patients who underwent transplantation for HCC, we designed and validated the R3-AFP model based on variables independently associated with recurrence post-LT (number of nodules, size of largest nodule, presence of MVI, nuclear grade, and last pre-LT AFP value). The R3-AFP model including last available pre-LT AFP value outperformed the original R3 model only based on explant features. The final R3-AFP scoring system provides a robust framework to design post-LT surveillance strategies, protocols, or adjuvant therapy trials, irrespective of criteria used to select patients with HCC for LT.
information on the intraoperative drain placement, drain amylase level on postoperative day one (... more information on the intraoperative drain placement, drain amylase level on postoperative day one (POD1), postoperative day of last drain removal and patients with POD1 amylase level > 5000 U/L were also excluded. Patients with early drain removal (3 days) were compared to those with late drain removal (4 days). Multi-variable regression models were used to evaluate the possible benefit of early drain removal after adjustment for multiple confounding factors. Results: 1066 patient were eligible for analysis. Patients with early drain removal had significantly lower mean rates of serious postoperative complications (p< 0.001), overall morbidity (p< 0.001), pancreatic fistula (p< 0.001), organ space infection (p=0.007), delayed gastric emptying (DGE) (p=0.026) and shorter mean in-hospital stay (p< 0.001). After adjustment for many confounding factors with multivariable regression models, the early group continued to have a significantly lower risk of all noted complications, except postoperative DGE. Conclusion: Early removal (3 days)of the drain after Whipple procedures is associated with lower rates of postoperative adverse outcomes when POD 1 drain amylase levels are < 5000 U/L.
2,444 liver transplant patients with HCC Pre-LT models at time of listing and last tumor reassess... more 2,444 liver transplant patients with HCC Pre-LT models at time of listing and last tumor reassessment Milan criteria AFP score Metroticket 2.0 Highlights At listing but not last tumor reassessment, Metroticket 2.0 showed better discriminative ability than AFP score for HCC recurrence. Discriminative power using respective thresholds was similar between models, either at listing or last tumor reassessment. Gaps and overlaps were observed when stratifying recurrence risk according to proposed thresholds. Combining both models at listing and at last tumor reassessment in a "within-ALL decision algorithm" could optimize candidate selection.
Modern liver surgeon must be equipped with excellent theoretical and clinical skills to perform a... more Modern liver surgeon must be equipped with excellent theoretical and clinical skills to perform a perfect liver resection. A particular and growing relevance is devoted to parenchyma sparing liver surgery (PSS). Indeed, reducing the sacrifice of functioning parenchyma is one of the keys of a successful surgery, once oncological issues are properly addressed. Intraoperative ultrasound together with oncological and anatomical new insights have enhanced the possibility to offer PSS even in advanced disease usually afforded with major resections or staged procedures or even considered unresectable. These complex hepatectomies are mainly performed with open surgery, while major or staged procedures could be faced with minimal access liver surgery (MALS): that is generating a potential conflict between open PSS and MALS major hepatectomies. An overall evaluation of oncological radicality, safety, salvageability, and quality of life suggest to prioritize PSS, which is always minimal invasive liver surgery in a hepatic-centered perspective, while MALS is not.
Patients with hydatid cysts in the liver used to present a therapeutic challenge. Although surgic... more Patients with hydatid cysts in the liver used to present a therapeutic challenge. Although surgical techniques have improved, considerable controversy still exists regarding the most effective operative technique. The main principle of the surgery is to eradicate the parasite and prevent intraoperative spillage of cyst contents avoiding peritoneal spread. Pericystectomy provides a radical treatment removing the whole cyst "en bloc" including the adventitia without resection of healthy liver tissue. Preoperative Treatment Albendazol orally 10-14mg/kg/day in two doses administered 2-4weeks before and after surgery.
ocal nodular fatty infiltration of the liver is a pseudotumor visualized as a highly echoic lesio... more ocal nodular fatty infiltration of the liver is a pseudotumor visualized as a highly echoic lesion on sonography. On computed tomography (CT), focal nodular fatty infiltration is generally characterized by a low-density area with no mass effect. 1 Although focal nodular fatty infiltration must be differentiated from primary liver cancer, a metastatic liver tumor, or hepatic hemangioma, this can be difficult with CT or sonography alone. When differential diagnosis is difficult from imaging investigations alone, biopsy proof of the tumor is necessary before therapy is commenced. The appearance of numerous small multifocal nodular fatty infiltrations in both hepatic lobes may mimic that of metastatic liver disease, leading to incorrect therapy. Particularly if the patient has had malignant disease in the past, multifocal nodular fatty infiltrations may be misdiagnosed, and incorrect therapy may be performed without adequate examination or differential diagnosis of the primary lesion. Although magnetic resonance imaging (MRI) and fine-needle biopsy are reportedly useful in diagnosing focal fatty infiltration of the liver, 2-4 the value of enhanced sonography has not been reported in this situation. We encountered a case of multifocal nodular fatty infiltration in which findings of the late parenchymal phase of enhanced sonography with Levovist (SH U 508A; Schering AG, Berlin, Germany) were useful in ruling out malignancy.
The Editors welcome topical correspondence from readers relating to articles published in the Jou... more The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses can be sent electronically via the BJS website (www.bjs.co.uk) or by post. All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Letters submitted by post should be typed on A4-sized paper in double spacing and should be accompanied by a disk.
Antecedentes: Los tumores benignos solidos del higado (TBSH) constituyen una patologia poco comun... more Antecedentes: Los tumores benignos solidos del higado (TBSH) constituyen una patologia poco comun. La mayoria de ellos son asintomaticos y de diagnostico accidental. Un pequeno numero de pacientes sufre complicaciones entre las que se encuentran la hemorragia y la transformacion maligna. Objetivo: Describir las complicaciones observadas en los pacientes operados por TBSH y analizar la conducta terapeutica y la evolucion postoperatoria de este grupo de enfermos. Diseno: Estudio clinico restrospectivo. Poblacion: De los 99 pacientes portadores de TBSH que fueron operados, 18 (18,1 por ciento) estaban complicados. En este grupo se incluyen: 6/49 (12,2 por ciento) hemangiomas, 8/21 (38,1 por ciento) adenomas, 2/16 (12,5 por ciento) hiperplasias nodulares focales, 1 hamartoma y 1 pseudotumor inflamatorio. La complicacion mas frecuente fue la hemorragica (66,6 por ciento) en 3 casos por biopsias preoperatorias. Todos los pacientes con adenomas asociados a hemorragia presentaban antecedentes de ingesta de anticonceptivos orales. Ademas se describen 3 transformaciones malignas, 1 necrosis infectada, 1 sindrome de Kasabach Merrit y 1 sindrome de Budd Chiari. Metodo: Con excepcion de un caso, todos los pacientes fueron resecados requiriendo de trasplante hepatico en 2 oportunidades. El paciente no resecado fue sometido a laparotomia exploradora y biopsia por un hemangioma con comportamiento agresivo. El seguimiento se realizo mediante evaluacion clinica y estudios por imagenes. Resultados: La morbilidad postoperatoria en los TBSH complicados fue de 4/18 (22,2 por ciento). No hubo mortalidad postoperatoria en este grupo, siendo la global de la serie de 1 por ciento (1 hemorragia cerebral por ruptura de una malformacion vascular). El seguimiento alcanzo un promedio de 3,2 anos (rango 1 mes-12 anos). Todos los pacientes resecados se hallan libres del tumor. El paciente con el hemangioma invasivo fallecio a los 26 meses del postoperatorio. Conclusiones: 1. La ingesta de anticonceptivos orales podria ser un factor importante en la paricion de complicaciones hemorragicas en pacientes con adenomas hepaticos. 2. La malignizacion es una complicacion a tener en cuenta en los adenomas y las hiperplasias nodulares focales. 3. Deben sospecharse patologias cerebrales asociadas en pacientes con tumores hepaticos benignos. 4. Debe evitarse la biopsia hepatica que no modifica la conducta terapeutica, ya que puede precipitar una complicacion...(AU)
Background: Although there is a worldwide need to expand the pool of available liver grafts, cada... more Background: Although there is a worldwide need to expand the pool of available liver grafts, cadaveric livers with severe steatosis (Ͼ60%) are discarded for orthotopic liver transplantation (OLT) by most centers. Methods: We analyzed patients receiving liver grafts with severe steatosis between January 2002 and September 2006. These patients were matched 1:2 with control patients without severe steatosis according to status the waiting list, recipient age, recipient body mass index (BMI), and model for end-stage liver disease (MELD) score. Primary end points were the incidence of primary graft nonfunction (PNF), and graft and patient survival. Secondary end points included primary graft dysfunction (PDF), the incidence of postoperative complications, and histologic assessment of steatosis in follow-up biopsies. We also conducted a survey on the use of grafts with severe steatosis among leading European liver transplant centers. Results: During the study period, 62 patients dropped out of the waiting list and 45 of them died due to progression of disease. Of 118 patients who received transplants 20 (17%) received a graft with severe steatosis during this period. The median degree of total liver steatosis was 90% (R ϭ 65%-100%) for the steatotic group. The steatotic (n ϭ 20) and matched control group (n ϭ 40) were comparable in terms of recipient age, BMI, MELD score, and cold ischemia time. The steatotic group had a significantly higher rate of PDF and/or renal failure. Although the median intensive care unit (ICU) and hospital stay were not significantly different between both groups, the proportion of patients with long-term ICU (Ն21 days) and hospital (Ն40 days) stay was significantly higher for patients with a severely steatotic graft. Sixty-day mortality (5% vs. 5%) and 3-year patient survival rate (83% vs. 84%) were comparable between the control and severe steatosis group. Postoperative histo-logic assessment demonstrated that the median total amount of liver steatosis decreased significantly (median: 90% to 15%, P Ͻ 0.001). Our survey showed that all but one of the European centers currently reject liver grafts with severe steatosis for any recipient. Conclusion: Due to the urgent need of liver grafts, severely steatotic grafts should be no longer discarded for OLT. Maximal effort must be spent when dealing with these high-risk organs but the use of severely steatotic grafts may save the lives of many patients who would die on the waiting list.
BackgroundA key tenet of clinical management of patients post liver transplantation (LT) is the p... more BackgroundA key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding.MethodsSystematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding (CRD42021244288).ResultsOf the 2478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post‐LT, yet it did not increase the risk of bleeding.ConclusionsBased on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT.
Background & Aims Patients with hepatocellular carcinoma (HCC) are selected for liver transpl... more Background & Aims Patients with hepatocellular carcinoma (HCC) are selected for liver transplantation (LT) based on pre-LT imaging ± alpha-foetoprotein (AFP) level, but discrepancies between pre-LT tumour assessment and explant are frequent. Our aim was to design an explant-based recurrence risk reassessment score to refine prediction of recurrence after LT and provide a framework to guide post-LT management. Methods Adult patients who underwent transplantation between 2000 and 2018 for HCC in 47 centres were included. A prediction model for recurrence was developed using competing-risk regression analysis in a European training cohort (TC; n = 1,359) and tested in a Latin American validation cohort (VC; n=1,085). Results In the TC, 76.4% of patients with HCC met the Milan criteria, and 89.9% had an AFP score of ≤2 points. The recurrence risk reassessment (R3)-AFP model was designed based on variables independently associated with recurrence in the TC (with associated weights): ≥4 nodules (sub-distribution of hazard ratio [SHR] = 1.88, 1 point), size of largest nodule (3–6 cm: SHR = 1.83, 1 point; >6 cm: SHR = 5.82, 5 points), presence of microvascular invasion (MVI; SHR = 2.69, 2 points), nuclear grade >II (SHR = 1.20, 1 point), and last pre-LT AFP value (101–1,000 ng/ml: SHR = 1.57, 1 point; >1,000 ng/ml: SHR = 2.83, 2 points). Wolber’s c-index was 0.76 (95% CI 0.72–0.80), significantly superior to an R3 model without AFP (0.75; 95% CI 0.72–0.79; p = 0.01). Four 5-year recurrence risk categories were identified: very low (score = 0; 5.5%), low (1–2 points; 15.1%), high (3–6 points; 39.1%), and very high (>6 points; 73.9%). The R3-AFP score performed well in the VC (Wolber’s c-index of 0.78; 95% CI 0.73–0.83). Conclusions The R3 score including the last pre-LT AFP value (R3-AFP score) provides a user-friendly, standardised framework to design post-LT surveillance strategies, protocols, or adjuvant therapy trials for HCC not limited to the Milan criteria. Clinical Trials Registration NCT03775863. Lay summary Considering discrepancies between pre-LT tumour assessment and explant are frequent, reassessing the risk of recurrence after LT is critical to further refine the management of patients with HCC. In a large and international cohort of patients who underwent transplantation for HCC, we designed and validated the R3-AFP model based on variables independently associated with recurrence post-LT (number of nodules, size of largest nodule, presence of MVI, nuclear grade, and last pre-LT AFP value). The R3-AFP model including last available pre-LT AFP value outperformed the original R3 model only based on explant features. The final R3-AFP scoring system provides a robust framework to design post-LT surveillance strategies, protocols, or adjuvant therapy trials, irrespective of criteria used to select patients with HCC for LT.
information on the intraoperative drain placement, drain amylase level on postoperative day one (... more information on the intraoperative drain placement, drain amylase level on postoperative day one (POD1), postoperative day of last drain removal and patients with POD1 amylase level > 5000 U/L were also excluded. Patients with early drain removal (3 days) were compared to those with late drain removal (4 days). Multi-variable regression models were used to evaluate the possible benefit of early drain removal after adjustment for multiple confounding factors. Results: 1066 patient were eligible for analysis. Patients with early drain removal had significantly lower mean rates of serious postoperative complications (p< 0.001), overall morbidity (p< 0.001), pancreatic fistula (p< 0.001), organ space infection (p=0.007), delayed gastric emptying (DGE) (p=0.026) and shorter mean in-hospital stay (p< 0.001). After adjustment for many confounding factors with multivariable regression models, the early group continued to have a significantly lower risk of all noted complications, except postoperative DGE. Conclusion: Early removal (3 days)of the drain after Whipple procedures is associated with lower rates of postoperative adverse outcomes when POD 1 drain amylase levels are < 5000 U/L.
2,444 liver transplant patients with HCC Pre-LT models at time of listing and last tumor reassess... more 2,444 liver transplant patients with HCC Pre-LT models at time of listing and last tumor reassessment Milan criteria AFP score Metroticket 2.0 Highlights At listing but not last tumor reassessment, Metroticket 2.0 showed better discriminative ability than AFP score for HCC recurrence. Discriminative power using respective thresholds was similar between models, either at listing or last tumor reassessment. Gaps and overlaps were observed when stratifying recurrence risk according to proposed thresholds. Combining both models at listing and at last tumor reassessment in a "within-ALL decision algorithm" could optimize candidate selection.
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