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Background/aims: Untreated hepatocellular carcinoma (HCC) has a notoriously poor prognosis, with a median survival of 1-8 months and a 5-year survival of -3%. Potentially curative surgical therapeutic options include partial hepatic resection with adequate margins and liver transplantation (LT). By current guidelines, transarterial chemoembolization (TACE) is the standard of care for the intermediate stage HCC, namely unresectable, multifocal disease confined to the liver in the absence of portal vein thrombosis and is used as bridging therapy for LT wait-listed candidates with HCC to limit tumour progression and dropout rate. TACE is contraindicated in patients with poor liver reserve with hyperbilirubinemia (bilirubin > or = 2 mg/ dL)., Methodology: In this study, 13 sequential HCC patients waitlisted for LT with total bilirubin level > or = 2 mg/dL, that underwent TACE prior to LT, were included. A mean of 4 TACE sessions were performed in each patient; 10 patients were either child A or B while 3 were in child C class., Results: The 30-day mortality rate was nil with minimal adverse effects and none of the patients showed procedure related morbidity such as hepatic decompensation. Hyperbilirubinemia did not affect outcomes significantly and tumour response rate was 54.8%. Thus, with careful selection of patients TACE can still be performed even in presence of hyperbilirubinemia thus preventing disease progression while they are waitlisted for LT.

Background/aims: Increased incidences of gallbladder disorders after esophagectomy and gastrectomy have been reported. Moreover, several researchers have reported increased incidences of gallbladder diseases in patients receiving long-term total parenteral nutrition. We studied the incidence of cholecystitis or cholestasis and determined its relationship with total parenteral nutrition; further, we compared the incidence after esophagectomy and after total gastrectomy., Methodology: We retrospectively studied 109 patients who underwent total gastrectomy or esophagectomy. These patients were divided into 2 groups, those who underwent total gastrectomy (TG group) and those who underwent esophagectomy (E group)., Results: The 2 groups did not significantly differ with respect to the mean duration of perioperative administration of total parenteral nutrition and the incidence rate of cholecystitis or cholestasis after esophagectomy., Conclusions: Postoperative hyperbilirubinemia after esophagectomy may not contribute to the development of gallbladder complications. We suggest that parenteral modalities such as tube feeding be initiated immediately after surgery for preventing gallbladder complications after esophagectomy. Further, a short duration of administration of total parenteral nutrition and immediate postoperative initiation of oral feeding may prevent gallbladder complications after esophagectomy and total gastrectomy.

Background/aims: A high incidence of hyperbilirubinemia and an increased incidence of gallbladder disorders after esophagectomy have been reported. Moreover, several studies have documented an increased incidence of gallbladder disease in patients receiving long-term total parenteral nutrition. We studied the incidence of cholecystitis and cholestasis and hyperbilirubinemia associated with total parenteral nutrition after esophagectomy., Methodology: We retrospectively studied 42 patients who underwent esophagectomy. These patients were divided into 2 groups: the hyperbilirubinemia group and the non-hyperbilirubinemia group. The incidence of cholecystitis or cholestasis after the surgery was compared between the 2 groups., Results: The mean total serum bilirubin level of the hyperbilirubinemia group (2.40±0.35mg/dL) was significantly higher than that of the non-hyperbilirubinemia group (1.20±0.34mg/dL; p<0.0001). No significant differences were observed between the 2 groups with respect to the mean duration for which total parenteral nutrition was required around the time of the operation (i.e. pre- and postoperatively) and the incidence rate of cholecystitis or cholestasis after esophagectomy., Conclusions: Hyperbilirubinemia after esophagectomy was frequently observed; however, it may not contribute to gallbladder problems. We suggest that parenteral modalities such as tube feeding should be initiated soon after surgery to prevent gallbladder problems after esophagectomy.

Background/aims: Major hepatectomy for perihilar cholangiocarcinoma has considerable risk of hepatic insufficiency even with preoperative portal vein embolization (PVE). Postoperative bilirubinemia is a great concern for hepatic surgeons., Methodology: Between 1998 and 2004, 120 patients with hilar bile duct cancer (n = 72) and intrahepatic cholangiocarcinoma (n = 48) underwent major hepatectomies with extrahepatic biliary resection. Of these, 63 patients underwent preoperative PVE to increase the future remnant liver (FRL) volume. Risk factors for early bilirubinemia after hepatectomy (> or = 2.5 mg on day 1) were evaluated using univariate and multivariate analyses., Results: The median FRL volumes before surgery in patients with and without PVE were 46% and 70%, respectively. The serum total bilirubin (TB) value on day 1 after hepatectomy was higher in patients with PVE than in patients without PVE (2.9 mg/dL vs 1.9 mg/dL, p < 0.0001). However, the significant risk factors for higher bilirubinemia on day 1 were preoperative TB value > or = 1.0 mg/ dL (p = 0.01), blood loss > or = 1.8L (p = 0.01), and blood transfusion (p = 0.03). Two patients developed postoperative hepatic failure and one patient died of surgery from septic complication., Conclusion: Major hepatectomies for perihilar cholangiocarcinoma were performed with acceptable safety using preoperative PVE. Postoperative early bilirubinemia was not associated with the FRL volume in this setting.

Background/aims: In living donor liver transplantation, hyperbilirubinemia is a common complication after donor hepatectomy, although donor liver function is principally normal. In this study, we therefore retrospectively analyzed factors affecting postoperative hyperbilirubinemia in the donor., Methodology: Between January 2005 and June 2007, 134 consecutive donors underwent donor hepatectomy for adult recipients at our center. Various parameters affecting postoperative hyperbilirubinemia related to donor and to the procedure, including preoperative total bilirubin (T-Bil) level, ratio of preoperatively estimated remnant liver volume and surgical duration were examined., Results: The mean postoperative maximum T-Bil level was 3.8 mg/dL, ranging from 1.2 to 11.9 mg/dL. Dividing patients into two groups by postoperative maximum T-Bil level, high T-Bil group (5 mg/dL or more) had a significantly higher preoperative T-Bil level and lower ratio of remnant liver volume than the low T-Bil group (less than 2 mg/dL) (P=0.007 and P<0.001, respectively). Moreover, similar analysis only in patients with right liver or extended right liver graft showed that preoperative higher T-Bil level and younger age were significantly associated with postoperative hyperbilirubinemia (P=0.009 and P=0.010, respectively)., Conclusions: Postoperative hyperbilirubinemia in donor was closely related to preoperative T-Bil level, ratio of remnant liver volume, and donor age.

Hyperbilirubinemia which developed after right hepatectomy is reported in a 66-year-old male. The application of hemodiafiltration treatment in the postoperative course of the patient and the effect of treatment in his healing process are summarized and discussed.

Background/aims: We investigated the effects of splenectomy on the reduction of excessive portal hypertension immediately after adult living-related donor liver transplantation, paying particular attention to peritransplanted portal pressure in seven adult patients., Methodology: We studied the relationship between portal hypertension and hyperbilirubinemia in small-for-size graft liver transplantation., Results: In the three cases, the portal pressures increased beyond 30 cmH2O after living-related donor liver transplantation, despite the right lobe graft, and these patients underwent splenectomy. After splenectomy, their portal pressures decreased below 25 cmH2O. The portal pressure underwent auxiliary orthotopic partial liver transplantation due to the hypercitrullinemia and did not change after surgery (9.5 to 11.5 cmH2O). Interestingly, the hyperbilirubinemia occurring after living-related donor liver transplantation were as the primary result of direct bilirubin except for the patient with citrullinemia. The posttransplanted portal pressures were controlled below 25 cmH2O in all patients, with their peak serum total bilirubin levels not exceeding 15 mg/dL, and the patients were discharged without major complications. Three patients underwent splenectomy, and did not suffer from serious infection. The reduction in excessive portal hypertension after living-related donor liver transplantation might prevent liver injury and post-transplant hyperbilirubinemia., Conclusions: However, splenectomy remains a life-threatening factor. Therefore, transplant surgeons encountering living-related donor liver transplantation must continue to seek out additional solutions to problems with excessive portal hypertension.

We describe the case of a 51-year-old woman with primary biliary cirrhosis who developed hyperbilirubinemia with transient liver dysfunction after undergoing endoscopic variceral ligation to control hemorrhaging from esophageal varices. After undergoing a variceal ligation, the serum total bilirubin increased from 4.0 mg/dL to 9.5 mg/dL, and the degree of liver failure worsened. She finally had to undergo a liver transplant. We discuss the mechanism of hyperbilirubinemia after endoscopic variceal ligation.

The main complications of endoscopic retrograde cholangiography and sphincterotomy are bleeding, pancreatitis, perforation and sepsis. Two cases of unexplained prolonged cholestatic jaundice in patients who underwent endoscopic retrograde cholangiography (ERC) for biliary obstruction due to choledocholithiasis are reported. The patients were admitted because of right upper quadrant pain, vomiting and jaundice. Laboratory tests showed increased levels of total and conjugated serum bilirubin and increased alkaline phosphatase. Ultrasound examination showed cholelithiasis and choledocholithiasis with bile duct dilatation. ERC with sphincterotomy was performed and gallstones obstructing the common bile duct were removed endoscopically. Following ERC and despite complete patency of the biliary tree, a progressive increase of total and conjugated bilirubin and of alkaline phosphatase was noted, associated with itching and total stool discoloration. The insertion of nasobiliary drain did not improve the jaundice. Prednisolone treatment for 12 days was associated with progressive restoration of serum bilirubin alkaline phosphatase to normal levels. It was postulated that the radiocontrast material used may have acted toxically on the liver with disruption of the canalicular plasma membrane. It is proposed that intrahepatic cholestasis should be added in the list of complications of endoscopic retrograde cholangiography.