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To investigate whether postoperative hepatic hemodynamics have an impact on graft function.Using a retrospective cohort with 262 adult living donor liver transplantation (LDLT) recipients, we discussed the relationship between postoperative hepatic hemodynamics and patient outcomes.According to the definition of early allograft dysfunction (EAD), the patients were classified into the EAD group (43 patients) and the non-EAD group (219 patients). In terms of postoperative hemodynamic parameters, there was no significant differences between these 2 groups regarding hepatic artery flow (HAF), hepatic artery velocity (HAV), portal vein flow (PVF), and portal vein velocity (PVV), except for the hepatic artery resistance index (HARI) which was somewhat higher in the EAD group on postoperative day 3 (POD3) (0.70 vs 0.61, P < .05). According to these results, we used a ROC curve and found that a HARI of 0.68 was the cutoff point (with 73.8% sensitivity and 58.3% specificity) for predicting EAD after LDLT. In addition, multivariate analysis showed that fulminant hepatic failure, pretransplant hepatorenal syndrome, and HARI ≥ 0.68 on POD3 were independent risk factors for postoperative EAD.Our results showed that postoperative hemodynamics might influence graft function by altering hepatic artery flow.

Only a few high-volume centers have reported the efficacy of laparoscopic liver resection (LLR) for patients with intrahepatic cholangiocarcinoma (ICC). The minimally invasive approach is still controversial for ICC, especially when dealing with large (≥5 cm) or multiple (≥2) ICCs.Patients with large and multiple ICCs who underwent LLR or open hepatectomy (OH) between January 2012 and June 2017 were included. Furthermore, 1:2 propensity score matching (PSM) was performed between the LLR group and the OH group. Short- and long-term outcomes were compared between the different techniques.After PSM, LLR resulted in significantly longer operation time (median 225 minutes vs 190 minutes, P = .006) and pringle maneuver time (median 50 minutes vs 32.5 minutes, P = .001). There was no statistically significant difference in postoperative hospital stay between the different approaches (median 6 days vs 7 days, P = .092). The grade III/IV complication rates were comparable between the groups (5.6% vs 11.1%, P = .868). In the PSM subset, there was no significant difference in terms of overall survival (P = .645) or disease-free survival (P = .827) between patients in the LLR group and in the OH group.The present study showed that patients who underwent LLR for large or multiple ICCs could obtain similar short- and long-term outcomes compared with those who underwent OH, and lymph node dissection (LND) was technically difficult but feasible during LLR.

Introduction: To systematically compare immediate postoperative tracheal extubation (IPTE) with conventional tracheal extubation (CTE) and to determine whether IPTE can achieve an enhanced recovery for adult patients underwent liver transplantation (LT) without additional risks. We designed a systematic review and meta-analysis., Methods: The RCTs, cohorts, case-controls, or case series that explored outcomes of IPTE after LT for adults were involved in our study. The Newcastle-Ottawa scale was used to assess the risk of bias., Results: A total of 15 studies (n = 4144) were included, consisting of 10 studies (retrospective cohorts; n = 3387) for quantitative synthesis and 5 studies (1 prospective cohort, and 4 case series; n = 757) for qualitative synthesis. The pooled estimates suggested IPTE could reduce time to discharge from ICU stay (TDICU) (mean difference [MD] -2.12 days, 95% confidence interval [CI] -3.04 to -1.19 days), time to discharge from the hospital (TDH) (MD -6.43 days, 95% CI -9.53 to -3.33 days), re-intubation rate (RI) (odds ratio [OR] 0.29, 95% CI 0.22-0.39), morbidity rate (MR) (OR 0.15, 95% CI 0.08-0.30) and graft dysfunction rate (GD) (IPTE vs CTE: 0.3% vs 3.8%, P < .01), and had comparable ICU survival rate (ICUS) (OR 6.67 95% CI 1.34-33.35) when compared with CTE after LT., Conclusions: IPTE can achieve an enhanced recovery for adult patients underwent LT without additional re-intubation, morbidity, and mortality risks. However, further work needs to be done to establish the extent definitively through carefully designed and conducted RCTs.

The outcomes following anterior approach (AA) hepatectomy in huge hepatocellular carcinoma (HCC) patients with diaphragmatic invasion (DI) remain unclear. This study compared the outcomes of single huge right HCC patients with and without DI after AA hepatectomy. A total of 203 consecutive patients with single huge right lobe HCC who underwent AA major hepatectomy were included. They were divided into group PDI (n = 53) and group ADI (n = 150) according to the presence or the absence of DI. Their short- and long-term outcomes were compared, and a subgroup analysis was performed. There were no significant differences regarding postoperative complications and 90-day mortality between the 2 groups. The overall survival (OS) and recurrence-free survival (RFS) rates were similar between the 2 groups. The subgroup analysis also showed that patients with tumor resection en bloc with part of the diaphragm had similar OS and RFS rates as those who underwent diaphragmatic resection after hepatectomy. Tumor diameter ≥ 15 cm, serum AFP level ≥ 400 ng/mL, and tumor grade of G4 and microvascular invasion are independent predictors of poor prognosis. For the single huge right lobe HCC patients with DI, AA major hepatectomy combined with diaphragmatic resection could offer similar OS and RFS as those without diaphragmatic invasion.

Postoperative bile leakage (BL) is a major complication of hepatic alveolar echinococcosis (HAE). The purpose of this study was to identify the risk factors for BL and to establish a simple scoring system for predicting BL.A total of 152 patients with HAE were included in the study between May 2004 and December 2016. The patient's baseline data, laboratory blood tests, imaging features, and surgical management were collected. Univariate and multivariate analyses were used to screen for factors to predict BL. The cutoff values for those factors and predictive value of a model were determined by receiver operative characteristic curve (ROC) analysis.BL was detected in 22 of the 152 patients. Univariate analyses showed significant differences in the lesion diameter, levels of lactate dehydrogenase (LDH), alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase and direct bilirubin (DBIL), inferior vena cava invasion, surface area of hepatectomy, blood loss and history of percutaneous transhepatic cholangial drainage between patients with and without BL. On multivariate analyses, DBIL > 7.1 μmol/L, LDH > 194 U/L, lesion diameter > 12 cm and a larger surface area of hepatectomy were independent predictors of BL. The resulting area under the ROC of the scoring model was 0.724 (95% CI, 0.646-0.793).The lesion diameter, DBIL, larger surface area of hepatectomy, and elevated LDH were the important factors affecting the occurrence of BL after surgery. The risk score model will help the clinician to assess BL before surgery. More studies are needed to confirm the scoring model and risk factors.

Rationale: Immediate postoperative tracheal extubation (IPTE) is one of the most important subject in recovery after surgery (ERAS) for liver transplantation. However, the criteria for IPTE is not uniform at present., Patient Concerns: We reported a successful IPTE in a liver transplant recipient with encephalopathy and a high Mayo end-stage liver disease (MELD) score of 41, which beyond the so-called criteria reported in the literature. The patient was 48-year-old man, admitted in September 2016 for end-stage liver cirrhosis secondary to hepatitis B., Diagnoses: End-stage liver cirrhosis secondary to hepatitis B with encephalopathy and a high MELD score of 41., Interventions: He was involved in our ERAS project and was extubated at the end of the liver transplantation in the operating room., Outcomes: As a result, the patient was not reintubated and had an excellent postoperative recovery, staying in intensive care unit (ICU) for just 2 days and discharged home on day 10., Lessons: We believed IPTE in liver transplant recipients with severe liver dysfunction is a meaningful challenge in ERAS for liver transplantation. Our case and literature review suggest 3 things: IPTE in liver transplantation is generally feasible and safe; the encephalopathy or high MELD score should not be the only limiting factor; and a more systematic predicting system for IPTE in liver transplantation should be addressed in future studies., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

The influence of the anatomical location of single large hepatocellular carcinoma (HCC) on outcomes following hepatic resection (HR) is still unclear. This study examined the role of anatomical location profiles as prognostic markers for patients with single large HCC undergoing HR.A total of 374 consecutive patients with single large HCC undergoing HR between January 2009 and July 2013 were included. They were divided into group same section (SS) group (n = 171) and different sections (DS) group (n = 203) according to their tumor's anatomical location. Short- and long-term outcomes were compared between the two groups.More patients in group DS had intraoperative blood loss of >1000 mL and needed intraoperative blood transfusion than those in group SS. There were no significant differences regarding postoperative complications and 30-and 90-day mortality between the two groups. The overall survival (OS) and recurrence-free survival (RFS) rates were significantly higher in group SS than group DS. The subgroup analysis showed that tumor in the same section was associated with better prognosis than those in different sections for both patients with tumor of ≤8 cm and of > 8 cm. Multivariate analysis revealed that age <60 years, portal hypertension, alpha-fetoprotein ≥400 ng/mL, tumor in different sections, microvascular invasion and poorly differentiated tumor are independent predictors of poor prognosis in patient with single large HCC.For patients with single large HCC, a tumor located in the same section may lead to better long-term survival and lower tumor recurrence rates than those in different sections following HR.

The influence of the biological relationship between the donor and the recipient is rarely discussed in living donor liver transplantation (LDLT), although it is believed to be an important risk factor in other types of organ transplantations. A total of 272 consecutive patients undergoing adult to adult right lobe LDLT were retrospectively analyzed and stratified into a nonbiologically related (NBR) group (69 patients) and a biologically related (BR) group (203 patients). The preoperative data and postoperative outcomes of both recipients and donors were evaluated.More than two-thirds of the recipients had histories of HBV infection, and hepatocellular carcinoma (HCC) was the main reason for the patients undergoing LDLT in both groups. The percentage of female donors in the NBR group was more than the percentage in the BR group (P = 0.000). There were no differences between the groups in postoperative laboratory testing or daily immunosuppression dose, and the complication rates in both the recipient and donor surgeries showed no significant differences. For patients with benign diseases, the cumulative 1-, 3-, 5-, and 10-year survival rate were 92.9% in the 4 periods in the NBR group and 89.1%, 87.6%, 83.7%, and 83.7%, respectively, in BR group, while for the patients diagnosed as HCC, if patients exceeding the Milan criteria were involved, the 5-year survival rate was 41.2%, compared to 82% for patients within the Milan criteria, which was nearly the same as for those with the benign disease. In conclusion, our findings suggested that the biological relationship between the donor and the recipient in adult to adult LDLT was not associated with the short- and long-term outcomes of recipients diagnosed with benign liver diseases and early stage HCC. Moreover, the criteria for patients diagnosed with HCC to undergo LDLT should be restrictively selected., Competing Interests: The authors have no conflicts of interest to disclose.