Palliation of proximal malignant biliary obstruction by endoscopic ...
Tu1064 Endoscopic Therapy for Post Liver Transplant Biliary Complications Is Safe and Effective
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AASLD Abstracts Tu1061 Impact of Multiple Tumors or Portal Hypertension on the Results of Second Hepatectomy for Recurrent Hepatocellular Carcinoma: A Single Center Experience Tsuyoshi Notake, Akira Kobayashi, Takahide Yokoyama, Akira Shimizu, Hiroaki Motoyama, Norihiko Furusawa, Hiroshi Sakai, Noriyuki Kitagawa, Kenta Yokoi, Kentaro Fukushima, Yohei Okubo, Shinichi Miyagawa Background & Aims: Roayaie et al. reported a 5-year overall survival (OS) rate of 67% after second hepatectomy for recurrent hepatocellular carcinoma (HCC) in highly selected patients with a single nodule, preserved liver function, and no- portal hypertension (PHT). The aim of this study was whether second liver resection can offer survival benefit for patients with multiple HCCs and/or PHT. Methods: We retrospectively studied 101 patients who had undergone second liver resection for recurrent HCC and stratified them into 3 groups according to the number of tumors and the presence of PHT, defined as a platelet count , 100,000/μL and/or the presence of esophageal varices: group A, patients with solitary tumor and no-PHT (n = 45); group B, those with either multiple tumor or PHT (n = 48); and Group C, those with both multiple tumor and PHT (n = 8). Overall survival (OS) and recurrence rate (RR) curves were constructed by the Kaplan-Meier method, and multivariate regression analysis was performed using the Cox proportional hazard model. Results: There was no 30-day mortality. The morbidity rate was comparable among the groups. The 5- year OS rates and the 2-year recurrent rates were 67% and 60% in group A, 62%and 55% in group B, and 38% and 88% in group C, respectively, showing no significant differences among the three groups. In a multivariate analysis, neither multiple tumors nor presence of PHT was a predictive factor for poor prognosis. Conclusions: We can extend the indication of second hepatectomy for recurrent HCC, at least, to the patients with either multiple HCCs or PHT. Tu1062 Impact of Tumor Size, Number of Tumors, Neutrophil-to-Lymphocyte Ratio and Des-Gamma-Carboxy Prothrombin in Liver Transplantation for Hepatocellular Carcinoma Tomoharu Yoshizumi, Ken Shirabe, Toru Ikegami, Takeo Toshima, Norifumi Harimoto, Yo-ichi Yamashita, Shohei Yoshiya, Yuji Soejima, Yoshihiko Maehara Background and Aims: The Milan criteria have significantly improved the outcome of liver transplantation (LT) for hepatocellular carcinoma (HCC), however the favorable outcomes have raised the question of whether selection criteria should be expanded. We have reported the outcome of living donor LT (LDLT) for otherwise unresectable and/or untreatable HCC patients and have proposed two risk factors for recurrence-free survival: tumor size . 5 cm and des-gamma-carboxy prothrombin (DCP) levels . 300 mAU/ml. The neutrophil-to- lymphocyte ratio (NLR), has recently emerged as a useful prognostic factor for recurrence of several gastroenterological malignancies. The aim of this study was to stratify risks for HCC recurrence after LDLT. Methods: We enrolled 160 adult recipients who had undergone LDLT for end-stage liver disease with HCC. The recurrence-free survival rates after LDLT were calculated. Risk factors for tumor recurrence were identified using univariate and multivariate analysis. Results: Sixty-one of 160 recipients (38%) did not meet the Milan criteria. The 1-, 3- and 5-year recurrence-free survival rates in the recipients were 92.0%, 86.8% and 85.6%, respectively. On univariate analysis, factors affecting recurrence-free survival were the sum of largest tumor size and number of tumors . 8, pre-transplant treatment for HCC, neutrophil-to-lymphocyte ratio (NLR) . 4, Alpha-fetoprotein .400 ng/ ml, des-gamma-carboxy prothrombin (DCP) .300 mAU/ml, and bilobar tumor distribution (P , 0.0001, P = 0.006, P , 0.0001, P , 0.0001, P , 0.0001, P , 0.0001, and P = 0.0002, respectively). Multivariate analysis identified that NLR . 4, the sum of largest tumor size and number of tumors . 8 and DCP .300 mAU/ml were independent risk factors for tumor recurrence after LDLT (P = 0.005, P = 0.0005, and P = 0.02, respectively). The enrolled recipients were divided into 3 groups according to score for risk factors for tumor recurrence. The recipients in Group 1 had no risk factor (n = 97). The recipients in Group 2 had a sum of risk factors equal to 1 (n = 41). The recipients in Group 3 had a sum of risk factors equal to or more than 2 (n = 20). The 1-, 3- and 5-year recurrence free survival rates in Group 1 were all 100%. The 1-, 3- and 5-year recurrence free survival rates in Group 2 were 94.7%, 80.5% and 75.1%, respectively. The 1-, 3- and 5-year recurrence free survival rates in Group 3 were 45.3%, 32.4% and 32.4%, respectively. The 1-, 3- and 5- year recurrence free survival rates in Group 3 were significantly worse than those of recipients in Group 1 and in Group 2 (P , 0.0001) Conclusions: The patients can be stratified according to the sum of 3 risk factors. LDLT should not be performed in patients with HCC who have more than 2 risk factors to achieve good outcome. Tu1063 Sarcopenia Is Poor Prognostic Factor in Patients With Hepatocellular Carcinoma After Hepatectomy Ken Shirabe, Yoshihiko Maehara Background Recently, sarcopenia was identified as a poor prognostic factor in patients with cancer or chronic disease. The present study investigated the effect of sarcopenia on short- and long-term surgical outcomes and identified potential prognostic factors for hepatocellular carcinoma (HCC) following hepatectomy. Methods Patient data were retrospectively collected for 186 consecutive patients who underwent hepatectomy for HCC with curative intent between January 2004 and December 2009. Patients were assigned to 2 groups according to the presence of sarcopenia. The clinicopathological, surgical outcome, and long-term survival data were analyzed and compared between the 2 groups. Results Sarcopenia was present in 75 patients (40.3%). It was significantly correlated with female gender, lower body mass index, and liver dysfunction, as indicated by abnormal serum albumin levels and indocyanine green retention test at 15-min values. In patients with and without sarco- penia, the 5-year overall survival rates were 71.3% and 88.6%, respectively, and the 5-year recurrence-free survival rates were 12.9% and 33.2%, respectively. Multivariate analysis S-1044 AASLD Abstracts revealed that sarcopenia was predictive of an unfavourable prognosis. Serum insulin-like growth factor (IGF) levels were weakly correlated with skeletal muscle mass. Neutrophil to lymphocyte ratio (NLR) and the presence of intrahepatic metastasis (im) of HCC was negatively correlated with skeletal muscle index after single and multiple regression test. Conclusion In conclusion, sarcopenia was an independent predictor of a worse overall survival and disease-free survival in patients with HCC after hepatectomy. And NLR, reflecting chronic inflammation may be related to sarcopenia. Tu1064 Endoscopic Therapy for Post Liver Transplant Biliary Complications Is Safe and Effective Tomas DaVee, Rajan Kochar, Aijaz Ahmed, Glen Lutchman, Tami Daugherty, Subhas Banerjee BACKGROUND: Biliary complications are common following orthotopic liver transplant (OLT) with a reported incidence of 20-30%. Endoscopic therapy is increasingly utilized in the diagnosis and treatment of post-OLT biliary complications and has replaced surgical and radiological management as the intervention of first choice. AIM: To evaluate the success and complication rates following endotherapy for post OLT biliary complications at our transplant center. METHODS: Retrospective review of a prospectively maintained database including all patients undergoing OLT at the Stanford University Hospital between 2006 and 2012 was performed. Clinical data, laboratory parameters, radiologic and endoscopic data were recorded for all patients with a post-OLT biliary complication. Technical success of endoscopic management was defined as successful biliary cannulation followed by endoth- erapy. Clinical success was defined as resolution of symptoms and normalization of imaging and laboratory abnormalities following completion of a course of endotherapy. Failure was defined as incomplete response to endotherapy requiring hepatojejunostomy (HJ) or repeat OLT. RESULTS: 101 post-OLT patients (65% male, mean age 55 yrs) required 419 ERCPs over the study period. The most common indications for ERCP were abnormal LFTs (97%) and abnormal biliary imaging (76%). Primary findings at ERCP in these 101 patients included: anastomotic stenosis (AS) in 54 (53.5%), non-anastomotic stenosis (NAS) in 15 (14.9%), normal cholangiogram in 14 (13.9%), biliary filling defect/s related to stones or casts in 6 (5.9%), papillary stenosis in 6 (5.9%), t-tube related obstruction in 2 (2%), bile leaks in 2 (2%) and other findings in 2 (2%). Of 101 patients referred for ERCP, 87 were determined to have biliary complications. The technical success rate of ERCP was 97.4% (408 of 419 attempted ERCPs). Patients with AS required a mean of 5.3 ERCPs for stricture resolution. The long-term clinical success rate for all biliary complications was 89.7% (78 of 87 patients) with a mean follow up of 43.2 months. The long-term clinical success rate for AS with endotherapy was 94.4% (51 of 54 patients). 3 patients with AS failed endotherapy and required HJ. NAS were managed using a combined endoscopic and interventional radiology approach. The long-term clinical success rate for treatment of NAS was 80.0% (12 of 15 patients). 3 patients with NAS required HJ. None required retransplantation. ERCP-associated complications were low and included the following: cholangitis (3.4%), stent migration (2.7%), post-ERCP pancreatitis (2.0%), stent occlusion (1.2%), and post-sphincterotomy bleeding (0.7%). CONCLUSION: (1) Endoscopic therapy with ERCP is effective and safe in the management of post-OLT biliary complications. (2) A combined endoscopic and IR approach results in a high success rate in managing NAS.
Transcript of Tu1064 Endoscopic Therapy for Post Liver Transplant Biliary Complications Is Safe and Effective
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Impact of Multiple Tumors or Portal Hypertension on the Results of SecondHepatectomy for Recurrent Hepatocellular Carcinoma: A Single CenterExperienceTsuyoshi Notake, Akira Kobayashi, Takahide Yokoyama, Akira Shimizu, HiroakiMotoyama, Norihiko Furusawa, Hiroshi Sakai, Noriyuki Kitagawa, Kenta Yokoi, KentaroFukushima, Yohei Okubo, Shinichi Miyagawa
Background & Aims: Roayaie et al. reported a 5-year overall survival (OS) rate of 67% aftersecond hepatectomy for recurrent hepatocellular carcinoma (HCC) in highly selected patientswith a single nodule, preserved liver function, and no- portal hypertension (PHT). The aimof this study was whether second liver resection can offer survival benefit for patients withmultiple HCCs and/or PHT. Methods: We retrospectively studied 101 patients who hadundergone second liver resection for recurrent HCC and stratified them into 3 groupsaccording to the number of tumors and the presence of PHT, defined as a platelet count, 100,000/μL and/or the presence of esophageal varices: group A, patients with solitarytumor and no-PHT (n = 45); group B, those with either multiple tumor or PHT (n = 48);and Group C, those with both multiple tumor and PHT (n = 8). Overall survival (OS) andrecurrence rate (RR) curves were constructed by the Kaplan-Meier method, and multivariateregression analysis was performed using the Cox proportional hazard model. Results: Therewas no 30-day mortality. The morbidity rate was comparable among the groups. The 5-year OS rates and the 2-year recurrent rates were 67% and 60% in group A, 62%and 55%in group B, and 38% and 88% in group C, respectively, showing no significant differencesamong the three groups. In a multivariate analysis, neither multiple tumors nor presenceof PHT was a predictive factor for poor prognosis. Conclusions: We can extend the indicationof second hepatectomy for recurrent HCC, at least, to the patients with either multipleHCCs or PHT.
Tu1062
Impact of Tumor Size, Number of Tumors, Neutrophil-to-Lymphocyte Ratioand Des-Gamma-Carboxy Prothrombin in Liver Transplantation forHepatocellular CarcinomaTomoharu Yoshizumi, Ken Shirabe, Toru Ikegami, Takeo Toshima, Norifumi Harimoto,Yo-ichi Yamashita, Shohei Yoshiya, Yuji Soejima, Yoshihiko Maehara
Background and Aims: The Milan criteria have significantly improved the outcome of livertransplantation (LT) for hepatocellular carcinoma (HCC), however the favorable outcomeshave raised the question of whether selection criteria should be expanded. We have reportedthe outcome of living donor LT (LDLT) for otherwise unresectable and/or untreatable HCCpatients and have proposed two risk factors for recurrence-free survival: tumor size . 5cm and des-gamma-carboxy prothrombin (DCP) levels . 300 mAU/ml. The neutrophil-to-lymphocyte ratio (NLR), has recently emerged as a useful prognostic factor for recurrenceof several gastroenterological malignancies. The aim of this study was to stratify risks forHCC recurrence after LDLT. Methods: We enrolled 160 adult recipients who had undergoneLDLT for end-stage liver disease with HCC. The recurrence-free survival rates after LDLTwere calculated. Risk factors for tumor recurrence were identified using univariate andmultivariate analysis. Results: Sixty-one of 160 recipients (38%) did not meet the Milancriteria. The 1-, 3- and 5-year recurrence-free survival rates in the recipients were 92.0%,86.8% and 85.6%, respectively. On univariate analysis, factors affecting recurrence-freesurvival were the sum of largest tumor size and number of tumors . 8, pre-transplanttreatment for HCC, neutrophil-to-lymphocyte ratio (NLR) . 4, Alpha-fetoprotein .400 ng/ml, des-gamma-carboxy prothrombin (DCP) .300 mAU/ml, and bilobar tumor distribution(P , 0.0001, P = 0.006, P , 0.0001, P , 0.0001, P , 0.0001, P , 0.0001, and P =0.0002, respectively). Multivariate analysis identified that NLR . 4, the sum of largest tumorsize and number of tumors . 8 and DCP .300 mAU/ml were independent risk factors fortumor recurrence after LDLT (P = 0.005, P = 0.0005, and P = 0.02, respectively). Theenrolled recipients were divided into 3 groups according to score for risk factors for tumorrecurrence. The recipients in Group 1 had no risk factor (n = 97). The recipients in Group2 had a sum of risk factors equal to 1 (n = 41). The recipients in Group 3 had a sum ofrisk factors equal to or more than 2 (n = 20). The 1-, 3- and 5-year recurrence free survivalrates in Group 1 were all 100%. The 1-, 3- and 5-year recurrence free survival rates inGroup 2 were 94.7%, 80.5% and 75.1%, respectively. The 1-, 3- and 5-year recurrence freesurvival rates in Group 3 were 45.3%, 32.4% and 32.4%, respectively. The 1-, 3- and 5-year recurrence free survival rates in Group 3 were significantly worse than those of recipientsin Group 1 and in Group 2 (P , 0.0001) Conclusions: The patients can be stratifiedaccording to the sum of 3 risk factors. LDLT should not be performed in patients with HCCwho have more than 2 risk factors to achieve good outcome.
Tu1063
Sarcopenia Is Poor Prognostic Factor in Patients With HepatocellularCarcinoma After HepatectomyKen Shirabe, Yoshihiko Maehara
Background Recently, sarcopenia was identified as a poor prognostic factor in patients withcancer or chronic disease. The present study investigated the effect of sarcopenia on short-and long-term surgical outcomes and identified potential prognostic factors for hepatocellularcarcinoma (HCC) following hepatectomy. Methods Patient data were retrospectively collectedfor 186 consecutive patients who underwent hepatectomy for HCC with curative intentbetween January 2004 and December 2009. Patients were assigned to 2 groups accordingto the presence of sarcopenia. The clinicopathological, surgical outcome, and long-termsurvival data were analyzed and compared between the 2 groups. Results Sarcopenia waspresent in 75 patients (40.3%). It was significantly correlated with female gender, lowerbody mass index, and liver dysfunction, as indicated by abnormal serum albumin levelsand indocyanine green retention test at 15-min values. In patients with and without sarco-penia, the 5-year overall survival rates were 71.3% and 88.6%, respectively, and the 5-yearrecurrence-free survival rates were 12.9% and 33.2%, respectively. Multivariate analysis
S-1044AASLD Abstracts
revealed that sarcopenia was predictive of an unfavourable prognosis. Serum insulin-likegrowth factor (IGF) levels were weakly correlated with skeletal muscle mass. Neutrophil tolymphocyte ratio (NLR) and the presence of intrahepatic metastasis (im) of HCC wasnegatively correlated with skeletal muscle index after single and multiple regression test.Conclusion In conclusion, sarcopenia was an independent predictor of a worse overallsurvival and disease-free survival in patients with HCC after hepatectomy. AndNLR, reflectingchronic inflammation may be related to sarcopenia.
Tu1064
Endoscopic Therapy for Post Liver Transplant Biliary Complications Is Safeand EffectiveTomas DaVee, Rajan Kochar, Aijaz Ahmed, Glen Lutchman, Tami Daugherty, SubhasBanerjee
BACKGROUND: Biliary complications are common following orthotopic liver transplant(OLT) with a reported incidence of 20-30%. Endoscopic therapy is increasingly utilized inthe diagnosis and treatment of post-OLT biliary complications and has replaced surgicaland radiological management as the intervention of first choice. AIM: To evaluate the successand complication rates following endotherapy for post OLT biliary complications at ourtransplant center. METHODS: Retrospective review of a prospectively maintained databaseincluding all patients undergoing OLT at the Stanford University Hospital between 2006and 2012 was performed. Clinical data, laboratory parameters, radiologic and endoscopicdata were recorded for all patients with a post-OLT biliary complication. Technical successof endoscopic management was defined as successful biliary cannulation followed by endoth-erapy. Clinical success was defined as resolution of symptoms and normalization of imagingand laboratory abnormalities following completion of a course of endotherapy. Failure wasdefined as incomplete response to endotherapy requiring hepatojejunostomy (HJ) or repeatOLT. RESULTS: 101 post-OLT patients (65% male, mean age 55 yrs) required 419 ERCPsover the study period. The most common indications for ERCP were abnormal LFTs (97%)and abnormal biliary imaging (76%). Primary findings at ERCP in these 101 patients included:anastomotic stenosis (AS) in 54 (53.5%), non-anastomotic stenosis (NAS) in 15 (14.9%),normal cholangiogram in 14 (13.9%), biliary filling defect/s related to stones or casts in 6(5.9%), papillary stenosis in 6 (5.9%), t-tube related obstruction in 2 (2%), bile leaks in 2(2%) and other findings in 2 (2%). Of 101 patients referred for ERCP, 87 were determinedto have biliary complications. The technical success rate of ERCP was 97.4% (408 of 419attempted ERCPs). Patients with AS required a mean of 5.3 ERCPs for stricture resolution.The long-term clinical success rate for all biliary complications was 89.7% (78 of 87 patients)with a mean follow up of 43.2 months. The long-term clinical success rate for AS withendotherapy was 94.4% (51 of 54 patients). 3 patients with AS failed endotherapy andrequired HJ. NAS were managed using a combined endoscopic and interventional radiologyapproach. The long-term clinical success rate for treatment of NAS was 80.0% (12 of 15patients). 3 patients with NAS required HJ. None required retransplantation. ERCP-associatedcomplications were low and included the following: cholangitis (3.4%), stent migration(2.7%), post-ERCP pancreatitis (2.0%), stent occlusion (1.2%), and post-sphincterotomybleeding (0.7%). CONCLUSION: (1) Endoscopic therapy with ERCP is effective and safein the management of post-OLT biliary complications. (2) A combined endoscopic and IRapproach results in a high success rate in managing NAS.
