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Hepatocellular carcinoma (HCC) is increasingly managed by liver resection first then salvage liver transplantation in case of recurrence within accepted criteria. Many reports compared the safety of the salvage against the primary surgery in the setting of deceased donation but the difference in case of living donation is not sufficiently defined. Salvage living donor liver transplantation (SLDLT) is believed to be a more challenging surgery than primary living donor liver transplantation (PLDLT) due to operative field adhesions, in addition to the inherent difficulties particularly short vasculobiliary stumps. In this report, we compared both pathways from a surgical perspective in a homogenous LDLT-only cohort.Over 15 years, 448 LDLTs for HCC were performed in a single liver transplant institution in Taiwan, including PLDLT (n = 348) and SLDLT (n = 100). A retrospective comparative review of the surgical outcomes of both pathways using a propensity score matching model (1-1, 100 pairs) was performed with adjustment for age, Child score and MELD score. The surgical outcome and survival were compared across 2 time eras.The operative data showed that SLDLT surgery encountered more extensive adhesions (57% vs. 0%, p 0.001), longer operative duration (650 vs. 618 min, p=0.04), and was followed by more incidence of re-exploration (16% vs. 5%, p=0.01), than the PLDLT surgery. There was no significant difference regarding the incidence of in-hospital mortality, vascular and biliary complications, or overall survival (OS). The 1-year OS of SLDLT was inferior to PLDLT in the first 50 cases (90% vs. 98%, p=0.03), then the same OS was found in the 2nd 50 cases (96% vs. 96%, p=0.9).The SLDLT surgery is a demanding lengthy procedure with extensive adhesions and possibility of frequent re-explorations. Significant case load and high centre volume are important factors for safe practice of SLDLT and better cumulative OS.

HCC is one of the leading causes of death worldwide. Liver transplantation including living donor transplantation is the best available treatment. We have analyzed our experience with LDLT in patients with HCC and HCV in order to determine if alpha feto-protein (AFP) is a better predictor of recurrence than the tumor burden. We have identified all patients with HCV related liver disease and HCC who have undergone LDLT in one center during the period from December 2000 to December 2014. Outcomes from the prospective database were compared for patients who met Milan criteria (single tumor ≤5 cm, maximum of 3 total tumors with none >3 cm) or not. Uni- and multi-variable analyses of factors influencing recurrence free survival (RFS) were performed. A total of 142 patients with HCC and HCV associated liver disease underwent LDTL during the study period. RFS was 96.4% at 1 years, 91.8% at 3 years and 91.8% at 5 years. Gender, model for End-Stage Liver disease (MELD), pre-transplant therapy, AFP level, tumor number, total tumor size were predictors of recurrence on univariable analysis. On multivariable analysis MELD score (Hazard ratio (HR) 1.16) and Log10 AFP (HR 3.14) were predictors of RFS. In the ROC curve analysis with an AUC of 0.76 the optimal cut-off value of AFP was 26ng/mL. In conclusion MELD score and pre-transplant AFP predict recurrence after LDLT for HCC with HCV infection.

Acute rejection (AR) of liver transplantation remains a formidable challenge for diagnostic medicine and biomarker discovery. We characterized AR-related microRNAs (miRNAs) and the underlying AR mechanisms in liver transplantation. Using a rat model of orthotopic liver transplantation (OLT) as well as microarrays, we compared the miRNA expression profiles between naive and AR livers on day 7 after OLT with short- (14 days, donor Dark Agouti [DA] liver into Lewis [LEW] recipient) and long-term (60 days, donor DA liver into Piebald Virol Glaxo [PVG] recipient) survival fates. The microarray analysis revealed that the levels of miR-301a in the lethal AR livers were significantly higher than in naive and tolerogenic AR livers. The reduced expression of miR-301a in inflamed livers suggested a difference between AR and inflammation in terms of miR-301a-mediated molecular events. Overexpression of hepatic miR-301a induced IL-6 production in rat primary hepatocytes. Hepatocytes overexpressing miR-301a were capable of transferring miR-301a to cocultured splenocytes through exosomes. These splenocytes then showed overexpression of miR-301a and downregulation of protein inhibitor of activated STAT3 (PIAS3) expression, resulting in the induction of T helper 17 cell differentiation. In conclusion, this report raises the possibility that hepatic miR-301a might potentially prove value as a biomarker of liver transplant rejection. We call for future research on this molecular target and the attendant pathways as liver transplant rejection and its early diagnosis continue to be veritable healthcare challenges.

BACKGROUND Because the outcome of liver transplantation for cholangiocarcinoma is often poor, cholangiocarcinoma is a contraindication for liver transplantation in most centers. Combined hepatocellular carcinoma and cholangiocarcinoma is a rare type of primary hepatic malignancy containing features of hepatocellular carcinoma and cholangiocarcinoma. Diagnosing combined hepatocellular carcinoma and cholangiocarcinoma pre-operatively is difficult. Because of sparse research presentations worldwide, we report our experience with living donor liver transplantation for combined hepatocellular carcinoma and cholangiocarcinoma. MATERIAL AND METHODS A total of 710 patients underwent living donor liver transplantation at our institution from April 2006 to June 2014; 377 of them received transplantation because of hepatocellular carcinoma with University of California San Francisco (UCSF) staging criteria fulfilled pre-operatively. Eleven patients (2.92%) were diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma confirmed pathologically from explant livers; we reviewed these cases retrospectively. Long-term survival was compared between patients diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma and patients diagnosed with hepatocellular carcinoma. RESULTS The mean age of the patients in our series was 60.2 years, and the median follow-up period was 23.9 months. Four patients were diagnosed with a recurrence during the follow-up period, including one intra-hepatic and three extra-hepatic recurrences. Four patients died due to tumor recurrence. Except for patients with advanced-stage cancer, disease-free survival of patients with combined hepatocellular carcinoma and cholangiocarcinoma compared with that of patients with hepatocellular carcinoma was 80% versus 97.2% in 1 year, and 46.7% versus 92.5% in 3 years (p

This study aimed to compare the outcomes of combined hepatic resection (HR) plus intraoperative radiofrequency ablation (RFA) and transarterial embolization (TAE) for Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC) in case-controlled patient groups using the propensity score. Methods: A total of 179 patients with multifocal HCC treated with HR plus RFA (n = 26) or TAE (n = 153) were retrospectively studied. All patients were classified as BCLC stage B and Child–Pugh class A. Analyses were performed over all participants as well as for propensity score-matched (1:3) patients to adjust for baseline differences. Cumulative overall survival (OS) and time to progression (TTP) were compared between the two groups using the Kaplan–Meier method, and independent predictors were identified by multivariate Cox regression analysis. Results: Patients treated with HR plus RFA had better OS and longer TTP than those with TAE (p = 0.011 and p

The PharmaCloud system, a cloud-based medication system, was launched by the Taiwan National Health Insurance Administration (NHIA) in 2013 to integrate patients' medication lists among different medical institutions. The aim of the preliminary study was to evaluate satisfaction with this system among physicians and pharmacists at the early stage of system implementation.A questionnaire was developed through a review of the literature and discussion in 6 focus groups to understand the level of satisfaction, attitudes, and intentions of physicians and pharmacists using the PharmaCloud system. It was then administered nationally in Taiwan in July to September 2015. Descriptive statistics and multiple regression were performed to identify variables influencing satisfaction and intention to use the system.In total, 895 pharmacist and 105 physician questionnaires were valid for analysis. The results showed that satisfaction with system quality warranted improvement. Positive attitudes toward medication reconciliation among physicians and pharmacists, which were significant predictors of the intention to use the system (β= 0.223, p 0.001). Most physicians and pharmacists agreed that obtaining signed patient consent was needed but preferred that it be conducted by the NHIA rather than by individual medical institutions (4.02 ± 1.19 vs. 3.49 ± 1.40, p 0.01).The preliminary study results indicated a moderate satisfaction toward the PharmaCloud system. Hospital pharmacists had a high satisfaction rate, but neither are physicians and community pharmacists. Continuously improvement on system quality has been performing based on the results of this preliminary survey. Policies and standardization processes, including privacy protection, are still warranted further actions to make the Taiwan PharmaCloud system a convenient platform for medication reconciliation.

Aim Despite the great advances and excellent outcomes of liver transplantation (LT), small-for-size (SFS) graft syndrome is a life-threatening complication that remains to be overcome. In the present study, we investigated the therapeutic effect of combined treatment with granulocyte colony-stimulating factor (G-CSF) and a dipeptidyl peptidase IV (DPP-IV) inhibitor on SFS liver graft syndrome. Methods The transplantation of small-sized Lewis donor livers into green fluorescent protein (GFP) transgenic Wistar rats was performed and the recipients were randomly assigned to one of four groups (without treatment, DPP-IV inhibitor treatment, G-CSF treatment and G-CSF/DPP-IV inhibitor combination). Recombinant human G-CSF was injected s.c. at a dose of 2 μg/kg per day starting 5 days prior to transplantation. G-CSF was combined with the p.o. administration of a DPP-IV inhibitor (2 mg/kg per day) after transplantation until the end of the observation period. Results The post-transplant survival and liver function of rats treated with G-CSF/DPP-IV inhibitor combination therapy were significantly improved with an increased number of recipient-derived GFP positive cells into the liver grafts. A confocal microscopy study showed cytokeratin (CK)-18 and GFP positive hepatic progenitor cells in the parenchyma of the liver allografts. Untreated rats and rats treated with either G-CSF or DPP-IV inhibitor did not exhibit the prolonged survival and had less GFP and CK-18 positive cells in the liver grafts after SFS LT. Conclusion Our results suggest that combined treatment with G-CSF and DPP-IV inhibitor may synergistically induce migration and differentiation of recipient-derived stem cells into the hepatic progenitor cells, resulting in the amelioration of SFS liver graft syndrome.

AIM: Sunitinib has shown benefit in patients with imatinib (IM)–resistant gastrointestinal stromal tumor (GIST). However, its advantages are somewhat diminished because of associated toxicities. Herein, we clarify the efficacy and safety of fractioned dose regimen of sunitinib by a pharmacokinetic and efficacy study. MATERIALS AND METHODS: Between 2001 and March 2013, a total of 214 patients with metastatic GIST was treated at Chang Gung Memorial Hospital. Among them, 55 (11.6%) patients who received sunitinib were investigated. One group of patients was administered with standard dose of once-daily sunitinib (standard dose group) and the other group was administered with standard total daily dose of sunitinib in fractioned doses (fractioned dose group). RESULTS: Thirty-two male and 23 female patients with a median age of 55 years received sunitinib. The median duration of sunitinib administration was 9.2 months. The clinical benefit was 65.2%. The mean peak blood level of sunitinib in patients with fractioned doses was significantly lower than that in those with once-daily dose (83.4 vs 50.1 ng/ml, P = .01). The rates of adverse effects of hand-foot syndrome, mucositis, and yellow skin were significantly decreased by fractioned doses of sunitinib. However, the progression-free and overall survival did not differ between patients with different treatment regimens. CONCLUSION: The fractioned dose regimen of sunitinib appears to be a safe and effective treatment for patients with IM-resistant/intolerant GISTs. Significantly decreased toxicity of this regimen could be explained by significantly lower peak sunitinib blood level. However, the treatment efficacy is not reduced by this regimen.

BACKGROUND Liver transplantation (LT) in overseas patients is a sensitive issue because of the possibility of organ trafficking and transplant tourism. In the Istanbul Summit, there was a call to develop standardized professional frameworks to prevent these practices. OBJECTIVES Our objectives are three-fold, to critically evaluate our professional framework, to study the demographic profiles, and to identify the outcome and impact of LT in overseas patients. METHODS Recipient and donor case records, e-mail communications, and medico-legal records were collected and analyzed for management strategy, demographic profile, donor and recipient characteristics, and outcome. RESULTS Only 5% of our total LT operations were for overseas patients. Forty-two (79%) were pediatric cases for which 39 (93%) were due to biliary atresia (P

Background Hepatitis C virus (HCV) recurrence in recipients who are viremic at time of liver transplantation (LT) is universal and carries poor prognosis. Pretransplant antiviral therapy to eradicate HCV reduces recurrence, but withdrawal rate is high. We conducted a short-course (4 weeks) of pegylated interferon alpha-2a (Peg-IFN-α2a) plus ribavirin (RBV) to prevent of HCV recurrence. Patients and methods From October 2009 to December 2011, eighty-eight consecutive HCV patients for living donor LT with potential living donor at Kaohsiung Chang Gung Memorial Hospital were included. Patients were divided into treatment and nontreatment group depending on presence of HCV-RNA. Fixed dosage of Peg-IFN-α2a (135 μg/week) plus RBV (10 mg/kg per day) were given for 4 weeks to treatment group who passed the 4-week waiting time according to clinical safety assessment. Results Forty-eight patients with genotypes 1, 2, and 3 (n=29/18/1) were treated with IFN and RBV combination for 4 (range, 1-9) weeks. Serum HCV RNA became undetectable at transplantation in 26 (54%) patients. No difference between genotypes 1 (n= 14, 48%) and 2/3(n=12, 63%, P=0.25) was observed. Most patients experienced cytopenia during treatment, but no mortality was noted. In the treatment group, 13 patients remained free of HCV infection 6 months after transplant. Virologic response at transplantation (48% vs. 100%, P=0.015) and genotype 2/3 (50% vs. 84%, P=0.01) are strong predictors of lower HCV recurrence rate. Multivariate analysis showed that genotype 2/3 was the only independent predictive factor affecting HCV RNA negativity 6 months after liver transplantation (OR:11.25; P=0.014). Conclusions Short-term pretransplant antiviral therapy is a feasible strategy in preventing HCV recurrence after LDLT especially in genotypes 2 and 3 recipients.

OBJECTIVES To systematically and quantitatively summarise the current evidence on the utility of the procalcitonin test (PCT) in discriminating pulmonary tuberculosis (TB) from other pulmonary infections. METHODS We searched MEDLINE, EMBASE and the Cochrane database up to August 2013 for studies that reported the performance of PCT alone or compared with other biomarkers in diagnosing pulmonary TB. We summarised PCT using forest plots, hierarchical summary receiver operating characteristic curves and bivariate random effects models. RESULTS We found nine qualifying studies covering 951 episodes of suspected TB along with 426 confirmed TB cases. The bivariate pooled sensitivity and specificity of PCT to distinguish TB from non-TB were respectively 42% (95%CI 30-56) and 87% (95%CI 63-96). The bivariate pooled sensitivity and specificity for PCT in distinguishing TB from bacterial pneumonia were respectively 78% (95%CI 67-86) and 85% (95%CI 78-90). Low heterogeneity was noted in studies comparing TB with bacterial pneumonia patients. CONCLUSION The results suggest consistently acceptable sensitivity and specificity of the PCT test in distinguishing TB from bacterial pneumonia. However, given the imperfect sensitivity and specificity of the test, medical decisions should be based on both the PCT test results as well as on clinical findings.

The outflow reconstruction of the right anterior sector in a right liver graft (RLG) with cryopreserved vascular grafts (CVGs) is crucial for preventing graft congestion in living donor liver transplantation (LDLT). The impact of the duration of cryopreservation has not been evaluated so far. From 2006 to 2009, 250 LDLT were performed: 47 of these patients (group 1) received CVGs stored for ≦1 year, and 33 patients (group 2) received CVGs stored for >1 year. Single or multiple segment 8 hepatic veins were reconstructed. The number of anastomoses did not affect vascular graft patency (P = 0.21). The length of the cryopreservation time did not affect the histological findings for CVGs. The preoperative and postoperative liver graft volumes were 783.8 ± 129.7 and 1102 ± 194.7 cc, respectively, for group 1 and 753.7 ± 158.5 and 1097.2 ± 178.7 cc, respectively, for group 2. The regeneration indices for liver grafts in the whole patient group, group 1, and group 2 were 48.9%, 47.4%, and 51.05%, respectively. In conclusion, the storage duration has no impact on the patency of CVGs in outflow reconstruction or on the regeneration of RLGs in LDLT. CVGs stored for >1 year can be safely used for the outflow reconstruction of RLGs in LDLT. Liver Transpl 20:173-181, 2014. © 2013 AASLD.

Liver grafts can at times have two hepatic arterial stumps. This can result in a dilemma whether to reconstruct single or both the arteries. Hepatic artery (HA) thrombosis is the most dreaded complication in pediatric living donor liver transplantation (LDLT) as it can result in biliary complications and subsequent graft loss. We herein report the feasibility of reconstructing single hepatic artery in pediatric living donor liver transplantation having two arterial stumps in the liver graft.From 2008 to 2010, 87 pediatric patients undergoing LDLT were divided into three groups. Group 1 (n = 20): two HA stumps with two HA reconstruction, Group 2 (n = 22): two HA stumps with one HA reconstruction and Group 3 (n = 45): one HA stump with one HA reconstruction. The decision regarding the reconstruction of single or multiple HAs was made depending on the pre-operative radiological and intraoperative assessments.The incidence of HA thrombosis (p = 0.126) and biliary complications (p = 0.617), was similar in the three groups.Single HA reconstruction does not increase the risk of biliary strictures in pediatric LDLT recipients having dual hepatic arterial stumps in the liver graft.

Polyhydroxyalkanoates (PHAs) are renewable and biodegradable polyesters which can be synthesized either by numerous of microorganisms in vivo or synthase in vitro. The synthesis of PHAs in vitro requires an efficient separation for high yield of purified enzyme. The recombinant Escherichia coli harboring phaC gene derived from Ralstonia eutropha H16 was cultivated in the chemically defined medium for overexpression of synthase in the present work. The purification and characteristics of PHA synthase from clarified feedstock by using aqueous two-phase systems (ATPS) was investigated. The optimized concentration of ATPS for partitioning PHA synthase contained polyethylene glycol 6000 (30%, w/w) and potassium phosphate (8%, w/w) with 3.25 volume ratio in the absence of NaCl at pH 8.7 and 4°C. The results showed that the partition coefficient of enzyme activity and protein content are 6.07 and 0.22, respectively. The specific activity, selectivity, purification fold and recovery of phaC(Re) achieved 1.76 U mg⁻¹, 29.05, 16.23 and 95.32%, respectively. Several metal ions demonstrated a significant effect on activity of purified enzyme. The purified enzyme displayed maximum relative activity as operating condition at pH value of 7.5 and 37°C. As compared to conventional purification processes, ATPS can be a promising technique applied for rapid recovery of PHA synthase and preparation of large quantity of PHA synthase on synthesis of P(3HB) in vitro.

ICP is an important cause of mortality in fulminant hepatic failure. The aim of this study was to prolonged survival in surgery-induced FHF rabbit with BAL. Four hours after induction of FHF, rabbits were connected to a 4-h whole blood perfusion through the BAL containing 1.2 × 10 9 fresh isolated porcine hepatocytes (estimated 30% of liver volume of rabbit) via an arterial-venous shunt. Survival times in control group, sham-BAL group and BAL group were14.4 ± 4.4 h, 12.6 ± 2.6 h and 22.6 ± 5.2 h, respectively (BAL vs. control, p = 0.026; BAL vs. sham-BAL, p = 0.006). BAL group remain ICP level less than 10 mmHg for near 13 h after FHF induction while 19 and 15 mmHg were observed in control and sham-BAL groups, respectively. BAL containing porcine hepatocytes significantly prolonged survival time by delayed increase of intracranial pressure compared with the control and sham-BAL groups.

Sorafenib is the only approved agent recommended by the American Association Study of Liver Disease guidelines for hepatocellular carcinoma patients in Barcelona Clinic Liver Cancer stage C.To calculate and compare overall survival rates in hepatocellular carcinoma patients in Barcelona Clinic Liver Cancer stage C treated with various therapies or supportive care alone.This was a retrospective study, in which medical data from 411 newly diagnosed hepatocellular carcinoma patients in Barcelona Clinic Liver Cancer stage C and Child-Pugh class A were analyzed and compared.Eighty-eight patients were treated with supportive care and 323 were treated with surgical resection (68/323, 21.1%), local ablation therapy (8/323, 2.5%), transarterial embolization (140/323, 43.3%), systemic chemotherapy or radiotherapy (96/323, 29.7%), and sorafenib (11/323, 3.4%). Median survival was 11 months (95% confidence interval, 9.0-13.1) in treated patients compared with 3.9 months in the supportive care group (hazard ratio, 0.45; 95% confidence interval, 0.35-0.59; p0.001). Patients who underwent surgical resection had the longest survival compared to patients undergoing other treatments (33.4 months versus 8.1 months, p0.001).Surgical resection resulted in excellent outcomes. Although sorafenib is currently recommended, oncologists should endeavour to select optimal candidates for surgical resection to gain more survival benefit.

Major modification of the 7th tumor-node-metastasis (TNM) staging system for hepatocellular carcinoma (HCC) was divided into 6th stage IIIA to 7th IIIA (multiple tumors, any >5 cm) and IIIB (tumors involving a major vessel). This study aimed to validate 6th and 7th TNM systems in prognostic prediction, then analyze the impact of time, Child-Pugh classification and treatment modalities in survival. A total of 5,611 and 3,217 HCC patients were enrolled between 1986–2002 (past period) and 2003–2010 (recent period), respectively. The Akaike information criteria (AIC) within a Cox proportional hazard regression model were used to demonstrate the discriminatory ability for staging systems. The 1-, 3-, and 5-year survival rates of past and recent periods were 44.8, 24.9, 17.1 %, and 65.5, 44.5, 34.6 %, respectively (p

Summary Background In 1973, Lin described a simplified technique of hepatic resection using his clamp and crush method. It allowed regional vascular control to reduce blood loss during parenchymal transection. This technique was aimed at avoiding hilar dissection and vascular clamping, thereby preventing ischemic–reperfusion injury of the remnant liver. Aims The objective of our study is to report our experience with Lin's technique and discuss its applicability. Methods The perioperative outcomes of patients who underwent hepatic resection with or without Lin's technique were analyzed. Multiple variables were also used to statistically compare outcomes between patients with a cirrhotic liver and a noncirrhotic one and results of performance by junior surgeons (JSs) and an experienced surgeon (ES). Results The perioperative outcome in patients undergoing hepatectomy with Lin's technique ( N = 18) showed a significantly shorter transection time, lower blood loss, and shorter hospital stay as compared with patients undergoing hepatectomy without Lin's clamp ( N = 17). Lin's technique was adopted in 29 patients. Eleven and 18 cases were operated on by the JSs and ES, respectively. The transection time was significantly longer in the JS group. Thirteen patients had a noncirrhotic liver whereas 16 patients had cirrhosis. There was no statistically significant difference in the perioperative outcomes between cases operated on by the JS and ES and between cases of patients with cirrhosis and those without cirrhosis. There was no incidence of hepatic failure within 90 days. Conclusion Lin's technique offers less blood loss, a shorter transection time, and a shorter hospital stay. The application of Lin's technique avoids the need for hilar vascular isolation and hilar clamping. JSs can perform hepatectomy with outcomes comparable to those produced by ESs by applying Lin's technique.

We describe our early and long-term experience with routine biliary reconstruction via a microsurgical technique in living donor liver transplantation (LDLT). One hundred seventy-seven grafts (including 3 dual grafts) were primarily transplanted into 174 recipients. The minimum follow-up was 44 months. Biliary reconstructions were based on biliary anatomical variations in graft and recipient ducts. The recipient demographics, graft characteristics, types of biliary reconstruction, biliary complications (BCs), and outcomes were evaluated. There were 130 right lobe grafts and 47 left lobe grafts. There were single ducts in 71.8%, 2 ducts in 26.0%, and 3 ducts in 2.3% of the grafts. The complications were not significantly related to the size and number of ducts, the discrepancy between recipient and donor ducts, the recipient age, the ischemia time, or the type of graft. The overall BC rate was 9.6%. The majority of the complications occurred within the first year, and only 1 patient developed a stricture at 20 months. No new complications were noted after 2 years. When the learning-curve phase of the first 15 cases was excluded, the overall BC rate was 6.79%, and the rate of complications requiring interventions was 2.5%. In conclusion, the routine use of microsurgical biliary reconstruction decreases the number of early and long-term anastomotic BCs in LDLT.

Clinical manifestations between hepatocellular carcinoma (HCC) and extra-hepatic primary malignancy (EHPM) are lack of large-scale study. We enrolled 14555 HCC patients between 1986 and 2013 retrospectively. The EHPM was classified as prior, synchronous and metachronous group based on before, within and after 6 months of HCC diagnosis, respectively. The incidence rate of EHPM is 3.91% (95% confidence interval [CI]: 3.60–4.23%). Urogenital cancers, kidney and bladder, were at unexpected higher ranks. Older in age, Child-Pugh A cirrhosis, negativity of HBsAg and anti-HCV, and earlier BCLC staging are independent factors associated with EHPM. The survival rates of EHPM improve over time and also better than HCC-alone. Cox proportional-hazards regression shows independent poor prognostic factors are age >60, male, AFP levels ≥400 ng/ml, positivity of HBsAg, Child-Pugh B vs. A, Non-metachronous group, respectively, treated with local ablation, transcatheter arterial embolization, radiotherapy and supportive care vs. surgery, respectively, TNM stage IIIA vs. I, and BCLC stages A, B, C and D vs. 0, respectively. Survival of EHPM improve could be explained by early diagnosis and improve treatment of cancers.

We hypothesized that a nomogram can accurately predict overall survival (OS) for patients with intrahepatic cholangiocarcinoma (ICC) after hepatectomy.A nomogram to predict OS based was developed using data from 185 ICC patients who had undergone hepatectomy. The nomogram was evaluated by concordance index (C-index), as well as testing calibration of predicted OS with observed OS for both internal and external cohorts.Ten clinicopathological independent factors for OS prediction were selected for use in the nomogram. For internal validation, the calibration curve for probability of OS showed good agreement between prediction by the nomogram and actual observation. In three external validation cohorts, the nomogram discrimination was also superior to two other staging systems.A nomogram integrating ten clinicopathological variables was developed that may assist in individual prognostic prediction of ICC after hepatectomy.

BACKGROUND Once-daily tacrolimus provides better compliance for transplant recipients. However, the conversion strategies of dosage and concentration from twice- to once-daily are not well studied. The aim of this study was to investigate the dosage of conversion, follow-up strategy, and safety of conversion to once-daily tacrolimus in stable and long-term recipients after living donor liver transplantation (LDLT). MATERIAL AND METHODS From January 2011 to November 2012, we selectively converted 35 stable LDLT recipients to once-daily tacrolimus based on 1-to-1 daily dose. The tacrolimus dosage, trough level, liver and renal function before conversion, 1 month, 3 months, 6 months, and 1 year after conversion were recorded. RESULTS Tacrolimus trough level dropped significantly after conversion (2.72±1.65 to 1.85±1.25 ng/mL, p

The study built up a new model by using Taiwan National Health Insurance Administration PharmaCloud system to facilitate medication reconciliation for pharmacists in the medication therapy management service.The model improved the patients' attitude and practices on rational use of medication as well as compliance to medication by the intervention.Phone follow-ups showed that the patients' practice and compliance scores on medication use were significant improved three months after the intervention. BackgroundThis study evaluated a medication therapy management service using the Taiwan National Health Insurance Administration's PharmaCloud system in a medical center in Taiwan. The new PharmaCloud System, launched in 2013, links a complete list of prescribed and dispensed medication from different hospitals, clinics, and pharmacies for all insured patients. MethodThe study included patients with polypharmacy (ź5 drugs) at a medication therapy management service from March 2013 to March 2014. A structured questionnaire was designed to collect patients' baseline data and record patients' knowledge, attitudes, and practice scores before and after the service intervention. Phone follow-ups for practice and adherence scores on medication use were performed after 3 months. ResultsThere were 152 patients recruited in the study. Scores for medication use attitudes and practice significantly increased after the service (attitudes: 40.06źźź0.26 to 43.07źźź0.19, pź

Laparoscopic cholecystectomy is gold standard for symptomatic gallstone and is world widely used for decades. With this minimally invasive approach, patients recovered from operation quicker than traditional open method. But biliary complication during this operation was not rare and had been reported. Literatures had suggested many preoperative image studies and intraoperative methods to avoid biliary complications. However, patients with biliary tree variation may have higher risk of bile duct injury during operation. Here, we present the patient with extremely rare biliary variation who encountered bile duct injury during laparoscopic cholecystectomy. The preoperative images, intraoperative findings, managements for complications, outcome and short review of the literature were recorded.

Adipose-derived stem cells (ASCs) are of great interest for the development of novel cell therapies due to their ease of isolation and expansion, immunosuppressive activity, and multilineage differentiation potential. However, the mechanisms underlying the therapeutic potential of ASCs remain to be elucidated. Others and we have shown that nuclear proteins such as histone H1 and high mobility group box 1 (HMGB1) play important roles in the maturation of dendritic cells (DCs). Furthermore, we previously demonstrated translocation of histone H1 from the nucleus to the cytoplasm and activation of mitogen-activated protein kinases (MAPKs) in DCs. In the present study, we confirmed that histone H1 does not alter the immunophenotype and immunosuppression potential of ASCs, but that histone H1 enhanced wound healing and increased interleukin (IL)-6 expression. Moreover, histone H1 treated-ASCs showed up-regulation of MAPKs extracellular-regulated kinase 1/2 (ERK1/2) and sequential NF-κB translocation. Finally, we found that culture in differentiation media supplemented with histone H1 enhanced ASC osteogenesis. In contrast, inhibition of histone H1 by small interfering RNA (siRNA) reduced osteogenic differentiation markers including ALP. These results suggest that histone H1 may be useful for induction of mesenchymal stem cells in tissue engineering and future potential ASC therapies.

Summary For pediatric living donor liver transplantation, portal vein complications cause significant morbidity and graft failure. Routine intra-operative Doppler ultrasound is performed after graft reperfusion to evaluate the flow of portal vein. This retrospective study reviewed 65 children who had undergone living donor liver transplantation. Seven patients were detected with suboptimal portal vein flow velocity following vascular reconstruction and abdominal closure. They underwent immediate on-table interventions to improve the portal vein flow. Both surgical and endovascular modalities were employed, namely, graft re-positioning, collateral shunt ligation, thrombectomy, revision of anastomosis, inferior mesenteric vein cannulation, and endovascular stenting. The ultrasonographic follow-up assessment for all seven patients demonstrated patent portal vein and satisfactory flow. We reviewed our experience on the different modalities and proposed an approach for our future intra-operative management to improve portal vein flow at the time of liver transplantation.

To compare the survival between surgical resection (SR) and radiofrequency ablation (RFA) in patients with hepatocellular carcinoma (HCC) in Barcelona Clinic Liver Cancer (BCLC) very early/early stage.Between 2002 and 2009, patients with newly diagnosed BCLC very early/early stage HCC who received SR or RFA were enrolled. Medical records were reviewed. The cumulative overall survival (OS) and disease-free survival (DFS) were compared.A total of 605 patients, including 143 very early (SR: 52; RFA: 91) and 462 early stages (SR: 208; RFA: 254) were enrolled. For very early stage, the 3- and 5-year OS rates were 98% and 91.5% for SR, and 80.3% and 72% for RFA, respectively (p=0.073). The 3- and 5-year DFS rates were 62.1% and 40.7% for SR, and 39.8% and 29.3% for RFA, respectively (p=0.006). Either multiple adjustment by Cox model or match analysis based on propensity score showed no significant difference in OS between the two groups. For early stage, the 3- and 5-year OS rates were 87.8% and 77.2% for SR, and 73.5% and 57.4% for RFA, respectively (p=0.001). The 3- and 5-year DFS rates were 59.9% and 50.8% for SR, and 28.3% and 14.1% for RFA, respectively (p0.001). After adjusting covariates, there was no significant difference in OS between the two groups. However, SR was superior to RFA in DFS.For HCC patients in BCLC very early/early stage, there was no significant difference in OS between SR and RFA. However, SR yielded better DFS than RFA.

Background Laparoscopic segmentectomy for liver tumor located in the left lateral segment (LLS) is thought to be a standard protocol nowadays with several advantages, such as small wound, few blood loss, and short hospital stay. However, there are still many disadvantages during executing laparoscopic LLS segmentectomy. This manuscript aims to present the technique to execute LLS segmentectomy with small incision, hanging maneuver without Pringle maneuver in patients with tumor at LLS of the liver. Material and methods Between November 2010 and July 2011, hepatectomies through small incision for nine patients with benign and malignant tumors were performed at Kaohsiung Chang Gung Memorial Hospital, Taiwan. Perioperative and postoperative results, such as operation time, blood loss, incisional width, and postoperative stay were used to determine consequents for this technique. Result Results demonstrated that modified LLS segmentectomy by the author’s team was performed successfully in patient with liver tumor with fewer blood loss, smaller incisional width, and lower hospital cost than traditional open surgery. In addition, the instrument cost and blood loss in our series were less than that in laparoscopic LLS segmentectomy in published literature. Conclusion Authors concluded that minimally incisional segmentectomy, with less cost and technical demanding, could be an alternative choice in patient with liver tumor at LLS.

Hepatocellular carcinoma (HCC) directly invading the gastrointestinal (GI) organs is rare and is associated with poor survival outcome. We report two patients with good long-term outcome following resection of HCC that invaded the stomach and duodenum, respectively. A literature review was conducted to elucidate the course of patients with this pathology. Two cases (57-year-old and 72-year-old males) with enlarged hepatic tumors directly invading the stomach and duodenum underwent hepatectomies with en-bloc resection of the involved organs. Both patients are still alive at 80 and 68 months following the surgery. Our literature review showed that most of the patients with this pathology have manifested, and died of persistent GI bleeding. Patients who were treated surgically had a statistically significant longer survival than those who were treated with non-surgical palliative treatments (P < 0.001). In addition, patients who were treated with surgery with curative intent tend to have a longer survival times than those who were treated with surgery to palliate the bleeding but the difference was not statistically significant (P < 0.174). Removing the tumor completely could significantly prolong the survival of patients with HCC invading the GI tract.

Background & Aims Non-alcoholic steatohepatitis (NASH) is recognized as the most severe form of non-alcoholic fatty liver disease, with likely progression to liver cirrhosis and hepatocellular carcinoma. However, there is no unified standard for diagnosis and therapeutics. This study aimed to characterize lipid transfer/metabolic proteins as non-invasive diagnostic markers, and to evaluate the therapeutic effects of phototherapy on the progression of NASH in rats. Methods Lewis rats given a choline-deficient and iron-supplemented l-amino acid-defined (CDAA) diet and Zucker fa/fa rats were used as a diet-induced and an obesity-related NASH models, respectively, with or without phototherapy. Results Serum apolipoprotein E and low molecular weight-adiponectin levels were gradually reduced and reached the lowest level at fatty liver/NASH stage both in CDAA diet-induced NASH model and in genetically obese model. Total-adiponectin levels were dramatically elevated after NASH was established in CDAA diet-induced NASH model. Phototherapy ameliorated hepatocyte apoptosis, inflammation, fibrosis, and insulin/leptin resistance caused by CDAA diet with alteration of the levels of lipid transfer/metabolic proteins and elevation of the circulating active form of vitamin D 3 . Vitamin D 3 supplementation ameliorated NASH progression in CDAA diet-induced NASH model. However, phototherapy failed to ameliorate the obesity and steatosis, suggesting that phototherapy may possess anti-inflammatory/fibrotic activity rather than anti-obesity/steatotic activity. Conclusions These results suggest that serum lipid transfer/metabolic proteins and vitamin D 3 status may be effective biomarkers for non-invasive diagnosis of NASH progression, and that phototherapy may be a good complementary therapy for NASH because of its regulation of lipid transfer/metabolic proteins and vitamin D 3 .

Background and Aims: The American Association for the Study of Liver Disease issued guidelines that proposed that hepatocellular carcinoma (HCC) can be diagnosed if a mass is larger than 2 cm in a cirrhotic liver and shows typical features of HCC at triphasic liver computed tomography (CT) or dynamic magnetic resonance imaging (MRI). In non-cirrhotic livers, the criteria were not applicable. The aim of the present study was to retrospectively analyze the sensitivity of imaging by samples of definite HCC postoperatively and test their application to diagnose HCC in non-cirrhotic livers. Methods: From January 2006 to November 2008, a total of 343 pathologically-diagnosed HCC patients via surgical resection were reviewed. Among the 343 patients, 204 patients had undergone liver CT examination, and 80 patients underwent MRI examination; serum α-fetoprotein had been checked for all 343 patients prior to operation. The diagnostic sensitivity of HCC by imaging was evaluated and compared in patients with/without cirrhosis by ultrasound and histology. Results: The diagnostic sensitivity of HCC by single imaging was approximately 65–80% (liver CT or MRI). A higher sensitivity of HCC diagnosis was found in patients with ultrasound-diagnosed cirrhosis than non-cirrhosis, but the difference in sensitivity disappeared after histologically-cirrhotic validation. The results indicated that regardless of the presence or absence of cirrhosis (histology), a typical vascular pattern could diagnose HCC with equally high sensitivity. Conclusions: We provide evidence that the sensitivity of HCC diagnosis by imaging is not influenced by the cirrhotic background. Further study is needed to validate the specificity and accuracy.

Isolated human hepatocytes have been extensively investigated due to clinical demand and scientific interest. With a limited supply of available liver tissue and the rapid loss of liver-specific functions in vitro, cryopreservation of human hepatocytes serves as an alternative way to maintain availability of hepatocytes. The purpose of this study was to evaluate the biological behaviors of long-term (more than 4 years) cryopreserved human hepatocytes on biomaterials, including polyvinyl alcohol (PVA), poly(ethylene-co-vinyl alcohol), polyvinylidene fluoride, commercial tissue culture polystyrene (TCPS), and collagen-coated TCPS. Cell attachment was observed by scanning electron microscopy and quantified by lactate dehydrogenase assay. Cell viability was assayed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide reduction activity. Cell functions were determined by albumin secretion and urea synthesis. Results indicated that human hepatocytes could be cryopreserved for more than 4 years without losing liver-specific functions. Also, PVA was proposed to serve as an appropriate and promising substrate for culturing long-term cryopreserved hepatocytes, maintaining high cell attachment and high level of liver-specific functions.

From March 1984 to November 2008, we performed 539 primary liver transplantations (LTs). Nineteen (19, 3.5%) were transplanted for end-stage liver disease secondary to primary biliary cirrhosis (PBC). There were 17 (89%) female and 2 (11%) male recipients. The overall mean age was 50.3 ± 6.3 yr. The mean model for end-stage liver disease, and Child-Turcotte-Pugh scores were 20.7 ± 2.1, and 11.0 ± 0.5, respectively. There were 2 (11%) United Network for Organ Sharing status 3, 16 (84%) 2B, and 1 (5%) 2A patients. Fourteen patients (14, 73.7%) underwent living donor LT, and five patients (26.3%) received deceased donor LT. The primary immunosuppression consisted of cyclosporine (n = 5) and tacrolimus (n = 14). Liver function returned to normal one month after transplantation. The overall mean follow-up was 5.8 ± 0.8 yr (range, four months to 15.7 yr). The overall one-, three-, and five-yr survival rates were 94.7%, 89.2%, and 89.2%, respectively. Without hepatitis B virus (HBV) prophylaxis, one patient acquired de novo HBV infection after receiving a graft from an anti-HBc(+) donor. Another patient developed recurrent hepatitis C infection and expired 25 months after transplantation. Our results showed that HBV prophylaxis was effective not only against de novo infection, but it also worked on pre-transplant HBV carrier with PBC and helped in virus clearance.

Small size and multiple ducts, particularly in right lobe liver grafts, are major factors that contribute to biliary complications in living donor liver transplantation. To improve the outcome of biliary reconstruction, further investigation and refinement of reconstruction techniques and management strategies are necessary. From March 2006 to June 2012, routine MBR was performed in 584 grafts in 581 consecutive LDLT (including 3 dual graft transplants). All biliary reconstructions were performed using microsurgical technique by a single microsurgeon. The classification of biliary reconstruction was based according to the number of ducts in the graft, the manner in which these ducts were reconstructed (with or without ductoplasty), and the conduit used (recipient duct or jejunum) to reconstruct the biliary tree. In duct-to-duct reconstruction, posterior wall first technique by using interrupted suture and continuous running and interrupted tie technique (combined method) for the anterior wall were performed. Recipient reduction ductoplasty was done, if necessary. In duct-to-jejunum reconstruction, enterotomy was performed first under microscope; then, the serosal and mucosal layers were sutured together using 8-0 prolene to facilitate the anastomosis. Posterior wall first by using interrupted suture technique and combined method for the anterior wall were also performed. Overall, there were 397 right and 184 left lobe grafts. Single duct opening was noted in 440 (75.34%), two duct openings in 135(23.12%), and three duct openings in 9 (1.54%) grafts. Duct-to-duct anastomosis was performed in 473 (81%) and duct-to-jejunum Roux limb in 111 (19%) biliary reconstructions. Size discrepancy in the graft and recipient ducts was noted in 394 (83.3%) reconstructions. The overall biliary complication was 7.9%. These included 19 (3.3%) bile leaks and 27 (4.6%) biliary strictures. The routine use of MBR capably surmounts the difficulties brought about by the anatomic variations and the size discrepancies between the graft and recipient hepatic ducts with excellent outcome.

Our objectives were to define the incidence and etiology of solitary pulmonary nodules (SPNs) in patients undergoing living donor liver transplantation (LDLT), describe a diagnostic approach to the management of SPNs in LDLT, and define the impact of SPNs on the overall survival of adult LDLT recipients. Nine patients (9/152, 5.9%) were diagnosed with an SPN on the basis of chest radiography findings during the pretransplant survey. All were male. The mean age was 52 years. All the patients had hepatitis B virus-related cirrhosis with hepatocellular carcinoma. All were asymptomatic for the lung lesion. All underwent contrast-enhanced chest computed tomography (CT) to verify the presence and possible etiology of the SPNs. In 3 cases, CT was used to definitely determine that there was no pulmonary nodule; in 2, CT led to a definite diagnosis of pulmonary tuberculosis. In 4, CT led to a definite identification of an SPN but not to an etiological diagnosis. Two patients underwent outright thoracoscopy and biopsy of their SPNs. Biopsy showed cryptococcosis in both patients. One received a therapeutic trial of an antituberculosis treatment, and repeat CT after 1 month showed a regression in the size of the SPN. A diagnosis of tuberculosis was made. One patient had an inconclusive whole body positron emission tomography scan and subsequently underwent thoracoscopy where biopsy showed tuberculosis. A concomitant malignancy, either primary lung cancer or metastasis from the liver tumor, was not identified. All patients were surviving with their original grafts and were lung infection-free. The overall mean posttransplant follow-up was 54 months (range = 33-96 months).

Biliary reconstruction using a microsurgical technique in living donor liver transplantation was routinely performed on 88 grafts primarily transplanted into 85 patients. All procedures were performed under a microscope by a single microsurgeon. Except for biliary atresia and Alagille syndrome, duct-to-duct reconstruction was performed. Stents were not used. The outcomes with microsurgical biliary reconstruction (MB) were compared with the outcomes of a cohort of 86 grafts in 85 patients that underwent conventional biliary reconstruction (CB). The identification of complications included only up to 12 months of follow-up for each recipient in both groups. The average graft duct sizes were 2.8 mm for MB and 3.4 mm for CB. Most complications occurred in the first 15 cases with MB, and these cases were considered to constitute the learning curve phase. The MB complication rate was 46.7% in the first 15 cases, 20.0% in the next 15 cases, and 5.4% in the last 55 cases. When the learning curve phase was excluded, the overall complication rate over time with MB (8.9%) was significantly lower than that with CB (21.9%). CB increased the risk of biliary complications by 2.5 times (relative risk: 2.5; attributable risk: 128; odds ratio: 2.9). In conclusion, routine MB is a technical innovation that leads to decreased early anastomotic complications in living donor liver transplantation.

The objective of this study was to describe the relationship between intimal dissection (ID) in the recipient hepatic artery (HA) and transarterial embolization (TAE) and highlight the reconstructive methods for the different types of ID encountered in living donor liver transplantation (LDLT). Fifty-four patients with hepatocellular carcinoma underwent LDLT. ID was classified as mild, moderate, or severe, and this classification was based on the extent of intimal injury. Mild, moderate, or severe ID were defined as ID that was less than one-quarter of the circumference of the HA, had reached one-half of the circumference of the HA, or was more than one-half of the circumference of the HA or involved the entire vessel wall, respectively. The reconstructive methods were based on the severity of ID encountered. Forty patients underwent TAE before LDLT, and 23 of these patients (57.5%) had ID. Nine patients had mild ID, 6 had moderate ID, and 8 had severe ID. In the 14 patients who did not undergo TAE, 4 had ID (28.6%; 3 mild and 1 severe). The other 10 patients (71.4%) had normal HA. In mild and moderate ID, the native HA was used after trimming of the HA until a healthy segment was encountered. In severe ID, the HA was reconstructed with alternative vessels. Two HA thromboses occurred postoperatively. TAE increased the risk of developing ID 2-fold. There was no graft loss or mortality in this series due to HA complications. In conclusion, ID of the HA is associated with pretransplant TAE among hepatocellular carcinoma patients undergoing LDLT. Intraoperative recognition of this complication and trimming until good vessel quality is encountered or using alternative vessels are important.

Optimal portal flow is one of the essentials in adequate liver function, graft regeneration and outcome of the graft after right lobe adult living donor liver transplantation (ALDLT). The relations among factors that cause sufficient liver graft regeneration are still unclear. The aim of this study is to evaluate the potential predisposing factors that encourage liver graft regeneration after ALDLT. The study population consisted of right lobe ALDLT recipients from Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan. The records, preoperative images, postoperative Doppler ultrasound evaluation and computed tomography studies performed 6 months after transplant were reviewed. The volume of the graft 6 months after transplant divided by the standard liver volume was calculated as the regeneration ratio. The predisposing risk factors were compiled from statistical analyses and included age, recipient body weight, native liver disease, spleen size before transplant, patency of the hepatic venous graft, graft weight-to-recipient weight ratio (GRWR), posttransplant portal flow, vascular and biliary complications and rejection. One hundred forty-five recipients were enrolled in this study. The liver graft regeneration ratio was 91.2 +/- 12.6% (range, 58-151). The size of the spleen (p = 0.00015), total portal flow and GRWR (p = 0.005) were linearly correlated with the regeneration rate. Patency of the hepatic venous tributary reconstructed was positively correlated to graft regeneration and was statistically significant (p = 0.017). Splenic artery ligation was advantageous to promote liver regeneration in specific cases but splenectomy did not show any positive advantage. Spleen size is a major factor contributing to portal flow and may directly trigger regeneration after transplant. Control of sufficient portal flow and adequate hepatic outflow are important factors in graft regeneration.

Volume mismatch is encountered when a single live donor cannot provide adequate graft volume to the recipient with a remnant liver volume which is safe for donation. Our objective is to present our experience in living donor liver transplantation using dual grafts. Record review of 4 dual graft recipients was done. The results were compared with 122 consecutive patients who received a single right lobe. All dual graft recipients were surviving with satisfactory liver function at a median follow-up of 21 months. Two recipients received 1 right and 1 left lobe graft, while the other 2 recipients received 2 left lobe grafts. One donor developed biloma and was managed by percutaneous drainage. The first recipient required re-laparotomy for postoperative bleeding. The second recipient underwent re-laparotomy for bile leak. The third recipient developed grade II decubitus ulcers due to a prolonged sedentary position. When compared with recipients who received a single right lobe, the operative time was prolonged in the dual graft group. There was no apparent increase in the rate of vascular and biliary complications or the incidence of acute cellular rejection. Actuarial patient survivals were comparable in both groups. Dual graft transplantation provides sufficient volume in the recipient without jeopardizing donor safety.

Background and Objectives To elucidate the clinicopathological correlations among vascular endothelial growth factor (VEGF), microvessel density (MVD) and tumor suppressor gene p53 in hepatocellular carcinomas (HCCs), we adopted a new definition of “VEGF overexpression.” Methods The expressions of VEGF, MVD, and p53 in 113 HCC specimens were analyzed by immunohistochemistry. Results VEGF expression in surrounding liver tended to be stronger (VEGF overexpression, 31%) than, or similar to (57%) that in HCCs (P = 0.001). P53 positivity was noted in 42 cases (37.1%). MVD ranged from 22 to 201 microvessels/field determined for 5 high-power fields. VEGF expression in HCCs was positively correlated with MVD (P = 0.001). VEGF overexpression is positively correlated with young age (P = 0.008), male gender (P = 0.01), hepatitis B viremia (P = 0.013), high α-fetoprotein levels (P

Background and Objective Atrial septal defect (ASD) is a common congenital heart defect. The course and impact of hemodynamically insignificant ASD in end-stage liver disease (ESLD) patients remains to be elucidated. Our objective is to present our experience in live donor liver transplantation in children with secundum type of ASD and to find out whether ASD has an impact on the outcome of liver transplantation. Patients and Methods Fourteen recipients (7 male, 7 female) whose median age was 14.2 months (range, 8–28) were included. The diagnosis of secundum type of ASD was confirmed by transthoracic 2-dimensional Doppler echocardiography preoperatively. The mean Child's score was 9.9, and the mean Pediatric End-stage Liver Disease Score was 14.7. The ASD were classified based on physiologic–hemodynamic (insignificant vs significant) and structural size (small [≤4 mm], medium [5–9 mm], or large [≥10 mm]) parameters. Only 1 patient showed hemodynamically significant ASD based on echocardiography and cardiac catheterization findings. Results Six small ASD spontaneously closed during the waiting period for transplantation. Four small ASD spontaneously closed posttransplant. The medium- and large-sized ASD persisted or increased in size posttransplantation. There were no perioperative cardiac complications. There were no neurologic complications. All patients are alive with the original grafts. The median follow-up was 49.7 months (range, 19.8–79.4). Conclusion Hemodynamic insignificant ASD seems to not impact the outcome of liver transplantation in children with ESLD. Further, this series demonstrated that transplantation can be successfully and safely performed in the presence of hemodynamically stable patients with small- to large-sized ASD.

This hospital-based analysis was conducted to identify prognostic factors of hepatocellular carcinoma (HCC) in a hepatitis B virus endemic area.A total of 6381 HCC cases, diagnosed from 1986 to 2002, were enrolled, and 2890 (42.3%) of them were not treated. Survival rates were analyzed by correlation with the national mortality databank. Missing data and correlations among prognostic factors were considered in the analysis.The overall 1-year, 3-year, 5-year, and 7-year survival rates were 44.3%, 24.9%, 17.1%, and 13%, respectively. Multivariate analysis revealed that the independent factors influencing survival were the initial treatment modality, degree of liver function impairment, hepatitis B surface antigen positivity, tumor status, and alpha-fetoprotein. Besides these well-known prognostic factors, high alanine aminotransferase (ALT) levels and a high aspartate aminotransferase (AST)/ALT ratio were identified as independent poor prognostic factors.This study, which considered untreated cases, missing data, and correlations between variables and official survival data sets, provides a large-scale comprehensive survival analysis. According to our results, high ALT and high AST/ALT were independent poor prognostic factors. Therefore, viral activity should be controlled in HCC patients, and patients with elevated AST/ALT ratios should be carefully monitored.