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Earlier diagnosis of hepatitis B virus (HBV) related hepatocellular carcinoma (HCC) increases treatment options and survival. The aim of this study is to evaluate which factors are associated with late presentation of HBV-related HCC.This is a retrospective review of all cases of HBV-related HCC diagnosed with late-stage/incurable HCC in New Zealand between 2003 and 2017. Cases were defined as patients with a positive hepatitis B surface antigen (HBsAg), and advanced (not amenable to potentially curable treatments) HCC at initial diagnosis. Patients were categorised into four groups according to potential reasons for late presentation: no previous diagnosis of HBV infection (Group A); known HBV diagnosis but not receiving HCC surveillance (Group B); known HBV diagnosis and receiving suboptimal HCC surveillance (Group C); and known HBV diagnosis and receiving optimised HCC surveillance (Group D).A total of 368 patients were reviewed. The average age at death was 59 years, and the majority of patients were Māori (39%), Pacific (34%) or Asian (20%). The incidence of patients presenting with HBV-related advanced HCC increased from 4.5 cases to 6.3 cases per million people over the review period. Of the cases, 40% were categorised into Group A, 26% into Group B, 12% into Group C and 23% in Group D. Overall, the median survival was 138 days, and this did not change during the study period. Patients receiving optimised surveillance (Group D) survived longer (mean 469 days) than patients in Group A (90 days), Group B (145 days) or Group C (152 days) (p0.05). Patients in Group D were more likely to be treated with transarterial chemoembolisation than patients in other groups (40% vs 15%, p0.05).This study has highlighted the need for improved rates of HBV diagnosis, better follow-up of those infected and the importance of optimal HCC surveillance. In New Zealand, HBV-related HCC disproportionately affects minority ethnic groups, and given the increasing incidence, provides a potential domain to reduce health inequities.

Liver transplantation (LT) is established treatment for adults and children with acute or chronic liver failure, however there are insufficient donor organs to meet demand and 14% of New Zealand patients have died waiting or were de-listed due to deterioration whilst on the waiting list. Live donor liver transplantation (LDLT) offers an alternative graft source that enables timely transplantation, but also carries the risk of morbidity and mortality for the donor.To report the initial experience with LDLT in New Zealand.Review of donor and recipient outcomes for the first 20 cases.129 potential live liver donors were assessed for 68 recipients. Donors were evaluated according to a multi-step protocol including independent donor advocacy. Twenty LDLT were performed on 7 adults and 13 paediatric recipients using 5 right lobe, 2 extended left lobe, 2 left lobe, and 11 left lateral section grafts. Five donors (25%) experienced postoperative complications, none of which were life-threatening. Four recipients had acute liver failure and 16 had chronic liver disease including one retransplant. There was a high rate of recipient biliary complications (40%) but graft and recipient survival is 100% to date.LDLT has been successfully introduced in New Zealand with good donor and recipient outcomes.

To report the first 5 years of paediatric liver transplantation (LTx) undertaken by the New Zealand Liver Transplant Unit.The records of all patients aged 0 to 15 years assessed for LTx between 1 January 2002 and 1 November 2006 were examined. Demographics, criteria for listing, waiting time, transplant-hospitalisation details, and outcome to date are reported.Thirty-eight children were assessed for LTx, of whom 33 were listed. One improved and was de-listed, 3 died on the waiting-list, and 1 remains on the list currently. Twenty-eight children have undergone 29 transplants; there were 25 primary and 4 re-transplants (3 had their primary transplant in Australia). The median wait-time was 122 days and median age at transplantation was 2 years 6 months. Fourteen (50%) were European, 10 (36%) Maori, 3 (11%) Pacific (mostly of Samoan, Tongan, Niuean, or Cook Islands origin), and 1 (3%) Asian. The most common diagnosis was extra-hepatic biliary atresia (59%) followed by alpha-1 antitrypsin deficiency and acute liver failure (14% each). There were 6 whole liver grafts and 23 partial liver grafts including 7 live donor and 10 split LTx. Median time in the Paediatric Intensive Care Unit (PICU) was 2 days and median hospital stay after LTx was 25 days. Time spent in Auckland immediately pre- and post-transplant for families from outside the region was a median of 14 weeks. Postoperative morbidity includes biliary leaks or strictures in 10 (36%), vascular thromboses in 7 (24%), and culture positive bacterial infection in 14 (50%). Twelve (43%) experienced one or more episodes of acute rejection, 3 developed chronic rejection, and post-transplant lymphoproliferative disorder (PTLD) occurred in 2 patients. Despite these problems, graft survival is 97% and patient survival is currently 100%. All patients of school age are currently attending school.Liver transplantation is now established in New Zealand as the treatment of choice for end-stage liver disease and acute liver failure in the paediatric population. Excellent outcomes that compare well with large overseas centres have been achieved.

Liver transplantation (LT) is potentially curative for early hepatocellular carcinoma (HCC) but time spent on the waiting list exposes patients to the risk of tumour progression prior to transplantation.We prospectively evaluated the outcome for New Zealand patients listed for LT with a pre-transplant diagnosis of HCC.Patients with 1 to 3 tumours, up to 5 cm in diameter, and no vascular invasion or extra-hepatic disease on imaging, were considered eligible for LT. The results were analysed by intention to treat from the time of listing.Fifty-nine patients were listed with a pre-transplant diagnosis of HCC between February 1998 and June 2004. Ten (17%) were de-listed before LT because of tumour progression, and 9 of 45 (20%) who underwent LT have experienced tumour recurrence up to 59 months post-transplant. For patients listed with a diagnosis of HCC, 5-year actuarial survival was 56.1% from the time of listing. For those listed and transplanted with a diagnosis of HCC, 5-year actuarial survival from the time of transplant was 63.5%. This is significantly worse than the 89.8% 5-year survival for patients transplanted without HCC over the same period (p=0.018) and this difference was entirely due to tumour recurrence.37% of patients listed according to our criteria were either de-listed due to tumour progression or experienced recurrence after LT. Based on this experience strategies aimed at preventing waiting list drop out have been adopted, however expansion of tumour-related selection criteria cannot be recommended without a concomitant increase in donor organ availability.

To examine the initial experience of laparoscopic donor nephrectomy (LDN) in New Zealand and compare it with open donor nephrectomy (ODN).All LDNs performed between June 2000 and June 2002 were reviewed. An equal number of ODNs were reviewed. Data were also collected on the recipients of the grafts. Key clinical data were prospectively collected; remaining data were collected by retrospectively reviewing patient charts. Auckland Hospital databases were accessed for costing analysis.Thirty five cases of each procedure had been performed. There has been 100% LDN graft survival. There was no significant difference in graft function (serum creatinine) at one and 12 months (p = 0.25 and 0.35) between the two groups. There was no significant difference in donor morbidity (26% vs 31%, p = 0.59). LDN resulted in a shorter hospital stay (3 vs 6.5 days, p0.0001) and convalescence period (3 vs 6 weeks, p0.0001). LDN was significantly more expensive (13 357 dollars vs 6713 dollars, p0.0001).LDN in the New Zealand setting provides effective grafts for renal transplant recipients and is safe for the donor. Advantages for the donor are a shorter hospital stay and convalescence period. The major disadvantage of LDN is its higher cost compared with ODN.

The majority of patients with hepatic malignancies are not suitable for potentially curative resection due to tumour size, location, inadequate hepatic reserve or widely spread disease. Radiofrequency ablation (RFA) is a novel technique of local tumour destruction by heat. The aim of this study was to report the initial experience with RFA in the management of primary and metastatic liver tumours in New Zealand.Patients who underwent RFA between February 2000 and August 2001 were included. The clinical, pathological and follow-up information of individual patients entered prospectively on a computerised database was collated and analysed.Thirty one procedures were performed in 30 patients (18 male, median age 58 years). Nineteen procedures were performed percutaneously under ultrasound guidance and twelve were carried out as part of a surgical procedure. Eight patients had primary tumours, and 22 patients had metastatic tumours (colorectal 9, neuroendocrine 7, non-colorectal non-neuroendocrine 6). The median diameter of treated lesions was 25 mm (range 5 60 mm). The median number of treated lesions per patient was 2 (range 1 6). Twenty four of the 31 procedures were classified as curative (all disease treated). Six patients with neuroendocrine tumours underwent cytoreduction only and were classified as palliative. Eight patients (4 percutaneous, 4 surgical) developed complications leading to 3 prolonged hospital stays (bile leak, abscess and burn). There was no treatment-related mortality. At a median follow up of 12 months (range 1 22 months), 6 patients (all treated with percutaneous RFA) have developed tumour recurrence in treated lesions, 5 patients have developed new liver lesions, 16 are alive and disease free, and 3 have developed extra hepatic disease.RFA is safe but significant complications can occur. RFA and enteral resection should not be undertaken together, as there is an increased risk of hepatic sepsis and abscess. RFA performed percutaneously is associated with a higher rate of recurrence than RFA performed at operation.

To summarise the transplant-related activity of the New Zealand Liver Transplant Unit over the first four years.The records of all patients assessed for liver transplantation between 1 December 1997 and 30 December 2001 were examined. Listing criteria, demographics, waiting time, transplant-hospitalisation details and long-term outcome for those who underwent liver transplantation were recorded.One hundred and eighty six patients over 14 years of age (acute liver failure 28, chronic liver disease 158) were assessed and 150 were listed for liver transplantation. Fifteen died waiting, 13 were de-listed (6 for cancer progression) and 14 remain listed. One hundred and nine liver transplants (including 1 combined heart-liver, 1 sequential liver-bone marrow and 5 re-transplants) were performed on 104 patients (13 acute liver failure, 96 chronic liver failure or hepatocellular carcinoma). The median waiting time was 2 days (range 0 5) for acute liver failure and 62 days (range 0 320) for other patients. Median age at transplant was 50 years (range 14-70); 73 patients (66%) were male; 71 (65%) were European; 13 (12%) Maori; 12 (11%) Pacific Islander; and 8 (7%) Asian. Median duration of surgery was 480 minutes (range 300 720 minutes); red cell transfusion 5 units (0 32); intensive care and total hospital stays were 2 (range 1 17) and 11 days (range 6 91). One transplanted patient died in hospital, 1- and 3-year patient survival was 94% and 87% and corresponding graft survival was 91% and 83%. Ninety three transplanted patients (89%) are alive. Of the 92 patients at least three months post-transplant, 62 (67%) were employed.Liver transplantation is now established in New Zealand as treatment of choice for acute and chronic liver failure and small hepatocellular carcinoma. Excellent outcomes have been attained in those transplanted to date. Reduction in waiting list mortality will require identification of and investment in strategies that will expand the donor organ availability.