Hepatobiliary Pancreat Dis Int

	2017 Vol. 16 No. 5
	Published: 2017-10-15


	pages 449-560
	REVIEW ARTICLES ORIGINAL ARTICLES/Transplantation ORIGINAL ARTICLES/Liver ORIGINAL ARTICLES/Biliary ORIGINAL ARTICLES/Pancreas LETTERS TO THE EDITOR

REVIEW ARTICLES

	458	Yoshino O, Perini MV, Christophi C, Weinberg L
		Perioperative fluid management in major hepatic resection: an integrative review ^Hot!
		BACKGROUND: Fluid intervention and vasoactive pharmacological support during hepatic resection depend on the preference of the attending clinician, institutional resources, and practice culture. Evidence-based recommendations to guide perioperative fluid management are currently limited. Therefore, we provide a contemporary clinical integrative overview of the fundamental principles underpinning fluid intervention and hemodynamic optimization for adult patients undergoing major hepatic resection. DATA SOURCES: A literature review was performed of MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials using the terms “surgery”, "anesthesia”, "starch”, "hydroxyethyl starch derivatives”, "albumin”, "gelatin”, "liver resection”, "hepatic resection”, "fluids”, "fluid therapy”, "crystalloid”, "colloid”, "saline”, "plasma-Lyte”, "plasmalyte”, "hartmann’s”, "acetate”, and “lactate”. Search results for MEDLINE and EMBASE were additionally limited to studies on human populations that included adult age groups and publications in English. RESULTS: A total of 113 articles were included after appropriate inclusion criteria screening. Perioperative fluid management as it relates to various anesthetic and surgical techniques is discussed. CONCLUSIONS: Clinicians should have a fundamental understanding of the surgical phases of the resection, hemodynamic goals, and anesthesia challenges in attempts to individualize therapy to the patient’s underlying pathophysiological condition. Therefore, an ideal approach for perioperative fluid therapy is always individualized. Planning and designing large-scale clinical trials are imperative to define the optimal type and amount of fluid for patients undergoing major hepatic resection. Further clinical trials evaluating different intraoperative goal-directed strategies are also eagerly awaited.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 458-469 . [Abstract] ( 204 ) [HTML 1KB] [PDF 932KB] ( 446 )

	470	Huang Y, Li MH, Hou M, Xie Y
		Peginterferon alfa-2a for the treatment of chronic hepatitis C in the era of direct-acting antivirals ^Hot!
		BACKGROUND: The availability of novel direct-acting antivirals (DAAs) represents a new era of curative hepatitis C virus (HCV) treatment, with over 95% of patients infected with HCV genotype 1 achieving sustained virological response (SVR). Nevertheless, the majority of patients globally are unable to access these treatments because of cost and infrastructure constraints and, thus, remain untreated and uncured. DATA SOURCE: Relevant articles of peginterferon (PegIFN)-based treatments in HCV and sofosbuvir-based treatments, simeprevir, daclatasvir/asunaprevir, ritonavir-boosted paritaprevir/ombitasvir/dasabuvir, and grazoprevir/elbasvir, were searched in PubMed database, including general population and special population. RESULTS: PegIFN in combination with ribavirin remains an important and relevant option for some patients, achieving SVR rates of up to 79% in genotype 1 and 89% in genotype 2 or 3 infections, which increases for patients with favorable IL28B genotypes. Triple therapy of DAA plus PegIFN/ribavirin is effective in treating difficult-to-cure patients infected with HCV genotype 3 or with resistance-associated variants. Owing to its long history in HCV management, the efficacy, tolerability and long-term outcomes associated with PegIFN alfa-2a are well established and have been validated in large-scale studies and in clinical practice for many populations. Furthermore, emerging data show that IFN-induced SVR is associated with lower incidences of hepatocellular carcinoma compared with DAAs. On the contrary, novel DAAs have yet to be studied in special populations, and long-term outcomes, particularly tumor development and recurrence in patients with cirrhosis and/or hepatocellular carcinoma, and reactivation of HBV in dually infected patients, are still unclear. CONCLUSION: In this interferon-free era, PegIFN-based regimens remain a safe and effective option for selected HCV patients.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 470-479 . [Abstract] ( 191 ) [HTML 1KB] [PDF 525KB] ( 429 )

ORIGINAL ARTICLES/Transplantation

	480	Li Y, Ruan DY, Jia CC, Zhao H, Wang GY, Yang Y, Jiang N
		Surgical resection versus liver transplantation for hepatocellular carcinoma within the Hangzhou criteria: a preoperative nomogram-guided treatment strategy ^Hot!
		BACKGROUND: With the expansion of surgical criteria, the comparative efficacy between surgical resection (SR) and liver transplantation (LT) for hepatocellular carcinoma is inconclusive. This study aimed to develop a prognostic nomogram for predicting recurrence-free survival of hepatocellular carcinoma patients after resection and explored the possibility of using nomogram as treatment algorithm reference. METHODS: From 2003 to 2012, 310 hepatocellular carcinoma patients within Hangzhou criteria undergoing resection or liver transplantation were included. Total tumor volume, albumin level, HBV DNA copies and portal hypertension were included for constructing the nomogram. The resection patients were stratified into low- and high-risk groups by the median nomogram score of 116. Independent risk factors were identified and a visually orientated nomogram was constructed using a Cox proportional hazards model to predict the recurrence risk for SR patients. RESULTS: The low-risk SR group had better outcomes compared with the high-risk SR group (3-year recurrence-free survival rate, 71.1% vs 35.9%; 3-year overall survival rate, 89.8% vs 78.9%, both P<0.001). The high-risk SR group was associated with a worse recurrence-free survival rate but similar overall survival rate compared with the transplantation group (3-year recurrence-free survival rate, 35.9% vs 74.1%, P<0.001; 3-year overall survival rate, 78.9% vs 79.6%, P>0.05). CONCLUSIONS: This nomogram offers individualized recurrence risk evaluation for hepatocellular carcinoma patients within Hangzhou criteria receiving resection. Transplantation should be considered the first-line treatment for high-risk patients.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 480-486 . [Abstract] ( 199 ) [HTML 1KB] [PDF 592KB] ( 460 )

	487	Luo Y, Ji WB, Duan WD, Shi XJ, Zhao ZM
		Delayed introduction of immunosuppressive regimens in critically ill patients after liver transplantation
		BACKGROUND: The manipulation of immunosuppression therapy remains challenging in patients who develop infectious diseases or multiple organ dysfunction after liver transplantation. We evaluated the outcomes of delayed introduction of immunosuppression in the patients after liver transplantation under immune monitoring with ImmuKnow assay. METHODS: From March 2009 to February 2014, 225 consecutive liver recipients in our institute were included. The delayed administration of immunosuppressive regimens was attempted in 11 liver recipients with multiple severe comorbidities. RESULTS: The median duration of non-immunosuppression was 12 days (range 5-58). Due to the infectious complications, the serial ImmuKnow assay showed a significantly low ATP level of 64±35 ng/mL in the early period after transplantation. With the development of comorbidities, the ImmuKnow value significantly increased. However, the acute allograft rejection developed when a continuous distinct elevation of both ATP and glutamyltranspeptidase levels was detected. The average ATP level measured just before the development of acute rejection was 271±115 ng/mL. CONCLUSIONS: The delayed introduction of immunosuppressive regimens is safe and effective in management of critically ill patients after liver transplantation. The serial ImmuKnow assay could provide a reliable depiction of the dynamics of functional immunity throughout the clinical course of a given patient.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 487-492 . [Abstract] ( 180 ) [HTML 1KB] [PDF 373KB] ( 431 )

ORIGINAL ARTICLES/Liver

	493	Zhao RC, Zhou J, Wei YG, Liu F, Chen KF, Li Q, Li B
		Cost-effectiveness analysis of transcatheter arterial chemoembolization with or without sorafenib for the treatment of unresectable hepatocellular carcinoma
		BACKGROUND: Transcatheter arterial chemoembolization (TACE) and TACE in combination with sorafenib (TACE-sorafenib) have shown a significant survival benefit for the treatment of unresectable hepatocellular carcinoma (HCC). Adopting either as a first-line therapy carries major cost and resource implications. The objective of this study was to estimate the relative cost-effectiveness of TACE against TACE-sorafenib for unresectable HCC using a decision analytic model. METHODS: A Markov cohort model was developed to compare TACE and TACE-sorafenib. Transition probabilities and utilities were obtained from systematic literature reviews, and costs were obtained from West China Hospital, Sichuan University, China. Survival benefits were reported in quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio (ICER) was calculated. Sensitive analysis was performed by varying potentially modifiable parameters of the model. RESULTS: The base-case analysis showed that TACE cost $26 951 and yielded survival of 0.71 QALYs, and TACE-sorafenib cost $44 542 and yielded survival of 1.02 QALYs in the entire treatment. The ICER of TACE-sorafenib versus TACE was $56 745 per QALY gained, which was above threshold for cost-effectiveness in China. Sensitivity analysis revealed that the major driver of ICER was the cost post TACE-sorafenib therapy with stable state. CONCLUSION: TACE is a more cost-effective strategy than TACE-sorafenib for the treatment of unresectable HCC.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 493-498 . [Abstract] ( 215 ) [HTML 1KB] [PDF 354KB] ( 465 )

	499	Lu Y, Hu JG, Lin XJ, Li XG
		Bone metastases from hepatocellular carcinoma: clinical features and prognostic factors
		BACKGROUND: Bone metastases (BMs) from hepatocellular carcinoma (HCC) is an increasingly common disease in Asia. We assessed the clinical features, prognostic factors, and differences in outcomes related to BMs among patients with different treatments for HCC. METHODS: Forty-three consecutive patients who were diagnosed with BMs from HCC between January 2010 and December 2014 were retrospectively enrolled. The clinical features were identified, the impacts of prognostic factors on survival were statistically analyzed, and clinical data were compared. RESULTS: The median patient age was 54 years; 38 patients were male and 5 female. The most common site for BMs was the trunk (69.3%). BMs with extension to the soft tissue were found in 14 patients (32.5%). Most (90.7%) of the lesions were mixed osteolytic and osteoblastic, and most (69.8%) patients presented with multiple BMs. The median survival after BMs diagnosis was 11 months. In multivariate analyses, survival after BM diagnosis was correlated with Karnofsky performance status (P=0.008) and the Child-Pugh classification (P<0.001); BM-free survival was correlated with progression beyond the University of California San Francisco criteria (P<0.001) and treatment of primary tumors (P<0.001). BMs with extension to soft tissue were less common in liver transplantation patients. During metastasis, the control of intrahepatic tumors was improved in liver transplantation and hepatectomy patients, compared to conservatively treated patients. CONCLUSIONS: The independent prognostic factors of survival after diagnosis of BMs were the Karnofsky performance status and Child-Pugh classification. HCC patients developed BMs may also benefit from liver transplantation or hepatectomy.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 499-505 . [Abstract] ( 164 ) [HTML 1KB] [PDF 379KB] ( 335 )

	506	Ulmer TF, Weiland A, Lurje G, Klink C, Andert A, Alizai H, Heidenhain C, Neumann U
		Comparative study of the effects of terlipressin versus splenectomy on liver regeneration after partial hepatectomy in rats
		BACKGROUND: Post-hepatectomy liver failure as a result of insufficient liver remnant is a feared complication in liver surgery. Efforts have been made to find new strategies to support liver regeneration. The aim of this study was to investigate the effects of terlipressin versus splenectomy on postoperative liver function and liver regeneration in rats undergoing 70% partial hepatectomy. METHODS: Seventy-two male Wistar rats were randomly assigned into three groups (n=24 in each group): 70% partial hepatectomy as control (PHC), 70% partial hepatectomy with splenectomy (PHS) or 70% partial hepatectomy with a micropump for terlipressin administration (PHT). Eight rats in each group were sacrificed on postoperative day (POD) 1, 3 and 7. To assess liver regeneration, immunohistochemical analysis of liver tissue using bromodeoxyuridine (BrdU) and Ki-67 labeling was performed. Portal venous pressure, serum concentrations of creatinine, urea, albumin, bilirubin and prothrombin time as well as liver-, body-weight and their ratio were determined on POD 1, 3 and 7. RESULTS: The liver-, body-weight and their ratio were not statistically different among the groups. On POD 1, 3 and 7 portal venous pressure in the intervention groups (PHT: 8.13 ±1.55, 10.38±1.30, 6.25±0.89 cmH2O and PHS: 7.50±0.93, 8.88 ±2.42, 5.75±1.04 cmH2O) was lower compared to the control group (PHC: 8.63±2.06, 10.50±2.45, 6.50±2.67 cmH2O). Hepatocyte proliferation in the intervention groups was delayed, especially after splenectomy on POD 1 (BrdU: PHS vs PHC, 20.85% ±13.05% vs 28.11%±10.10%; Ki-67, 20.14%±14.10% vs 23.96% ±11.69%). However, none of the differences were statistically significant. CONCLUSIONS: Neither the administration of terlipressin nor splenectomy improved liver regeneration after 70% partial hepatectomy in rats. Further studies assessing the regulation of portal venous pressure as well as extended hepatectomy animal models and liver function tests will help to further investigate mechanisms of liver regeneration.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 506-511 . [Abstract] ( 185 ) [HTML 1KB] [PDF 321KB] ( 458 )

ORIGINAL ARTICLES/Biliary

	512	Kim NH, Kim HJ, Bang KB
		Prospective comparison of prophylactic antibiotic use between intravenous moxifloxacin and ceftriaxone for high-risk patients with post-ERCP cholangitis ^Hot!
		BACKGROUND: The use of prophylactic antibiotics before endoscopic retrograde cholangiopancreatography (ERCP) is recommended by all major international gastroenterological societies, especially in the presence of an obstructed biliary system. This study compared the occurrence rate of post-procedural complications, including cholangitis and septicemia, between prophylactic intravenous moxifloxacin and ceftriaxone in patients with bile duct obstruction scheduled for therapeutic ERCP. METHODS: From November 2013 to July 2015, 86 consecutive patients with biliary obstruction with one or more factors predicting benefits of antibiotic prophylaxis prior to ERCP were included in the current randomized open-label non-inferiority trial (ClinicalTrial.gov identifier NCT02098486). Intravenous moxifloxacin (400 mg/day) or ceftriaxone (2 g/day) were given 90 minutes before ERCP, and were administered for more than 3 days if the patient developed symptoms and signs of cholangitis or septicemia. Recalcitrant cholangitis was defined as persistence of cholangitis for more than 5 days after ERCP or recurrence of cholangitis within 30 days after ERCP. RESULTS: Recalcitrant cholangitis occurred in 1 (2.3%) and 2 (4.8%) patients receiving intravenous moxifloxacin and ceftriaxone group, respectively (P=0.612). Septicemia was noted in 1 (2.3%) and 1 (2.4%) patient in intravenous moxifloxacin and ceftriaxone group, respectively (P=1.0). The mean hospital stay was also not significantly different between the moxifloxacin and ceftriaxone groups (8.8±7.2 vs 9.1±9.4 days, P=0.867). Antibiotic resistance of the isolated pathogens by in vitro activity assay was noted in 1 (2.3%) and 2 (4.8%) patients in the moxifloxacin and ceftriaxone group, respectively (P=0.612). CONCLUSION: Intravenous moxifloxacin is not inferior to intravenous ceftriaxone for the prophylactic treatment of post-ERCP cholangitis and cholangitis-associated morbidity.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 512-518 . [Abstract] ( 213 ) [HTML 1KB] [PDF 427KB] ( 402 )

	519	Ma F, Yang Y, Wang JD, Quan ZW, Zhou D
		Helicobacter pylori and 17β-estradiol induce human intrahepatic biliary epithelial cell abnormal proliferation and oxidative DNA damage
		BACKGROUND: Biliary cancers are more common in females, and previous studies have suggested that Helicobacter pylori (H. pylori) exists in the biliary system. However, the effects of H. pylori infection and estrogen on the biological behaviors of human biliary epithelium mucosa remain unknown. The present study aimed to clarify their effects on the proliferation, apoptosis, migration and oxidative DNA damage of a human intrahepatic biliary epithelial cell (HIBEC) line in vitro. METHODS: HIBECs were co-cultured with 17β-estradiol (at 10-9 mol/L, 10-7 mol/L, and 10-5 mol/L) and H. pylori (at MOI=0.5:1, 1:1, and 2:1) and continuously passaged until the 15th generation (approximately 45 days). Then, the following assays were performed. HIBEC proliferation was measured using the CCK-8 assay, plate clone-formation assay and by determining Ki-67 expression with immunocytochemistry; cell apoptosis and migration were investigated using Annexin-V/PI and transwell assays, respectively; and reactive oxygen species (ROS) and 8-hydroxy-2’-deoxyguanosine (8-OHdG) production were detected by flow cytometry and immunofluorescence staining combined with confocal laser scanning microscopy, respectively. The results were the basis for evaluating the level of oxidative stress and the related DNA damage in HIBECs. RESULTS: HIBECs maintained a normal morphology and vitality when treated with 17β-estradiol (at 10-9 mol/L) and H. pylori (at MOI=0.5:1 and 1:1). 17β-estradiol at 10-7 mol/L and 10-5 mol/L and H. pylori at MOI=2:1, by contrast, caused cell death. Compared with controls, HIBECs treated with 17β-estradiol (10-9 mol/L) and H. pylori (MOI=1:1) had a higher up-regulation of proliferation, Ki-67 expression, clone formation, migration activity and the expression of ROS and 8-OHdG and exhibited a down-regulation of apoptosis. The above effects were further increased when 17β-estradiol and H. pylori were combined (P<0.05). CONCLUSIONS: H. pylori and 17β-estradiol, separately or in combination, promoted cell proliferation and suppressed apoptosis of HIBECs in vitro. The above phenomena might be related to oxidative stress and its subsequent DNA damage with H. pylori and 17β-estradiol.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 519-527 . [Abstract] ( 183 ) [HTML 1KB] [PDF 1097KB] ( 428 )

ORIGINAL ARTICLES/Pancreas

	528	El Nakeeb A, Sultan AM, Atef E, Salem A, Abu Zeid M, Abu El Eneen A, El Ebidy G, Abdel Wahab M
		Tailored pancreatic reconstruction after pancreaticoduodenectomy: a single-center experience of 892 cases
		BACKGROUND: Pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debatable even for pancreatic surgeons. Ideally, pancreatic reconstruction after PD should reduce the risk of postoperative pancreatic fistula (POPF) and its severity if developed with preservation of both exocrine and endocrine pancreatic functions. It must be tailored to control the morbidity linked to the type of reconstruction. This study was to show the best type of pancreatic reconstruction according to the characters of pancreatic stump. METHODS: We studied all patients who underwent PD in our center from January 1993 to December 2015. Patients were categorized into three groups depending on the presence of risk factors of postoperative complications: low-risk group (absent risk factor), moderate-risk group (presence of one risk factor) and high-risk group (presence of two or more risk factors). RESULTS: A total of 892 patients underwent PD for resection of periampullary tumor. BMI >25 kg/m2, cirrhotic liver, soft pancreas, pancreatic duct diameter <3 mm, and pancreatic duct location from posterior edge <3 mm are risk variables for development of postoperative complications. POPF developed in 128 (14.3%) patients. Delayed gastric emptying occurred in 164 (18.4%) patients, biliary leakage developed in 65 (7.3%) and pancreatitis presented in 20 (2.2%). POPF in low-, moderate- and high-risk groups were 26 (8.3%), 65 (15.7%) and 37 (22.7%) patients, respectively. Postoperative morbidity and mortality were significantly lower with pancreaticogastrostomy (PG) in high-risk group, while pancreaticojejunostomy (PJ) decreases incidence of postoperative steatorrhea in all groups. CONCLUSIONS: Selection of proper pancreatic reconstruction according to the risk factors of patients may reduce POPF and postoperative complications and mortality. PG is superior to PJ as regards short-term outcomes in high-risk group but PJ provides better pancreatic function in all groups and therefore, PJ is superior in low- and moderate-risk groups.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 528-536 . [Abstract] ( 189 ) [HTML 1KB] [PDF 299KB] ( 394 )

	537	Liang X, Shi LG, Hao J, Liu AA, Chen DL, Hu XG, Shao CH
		Risk factors and managements of hemorrhage associated with pancreatic fistula after pancreaticoduodenectomy
		BACKGROUND: Post-pancreaticoduodenectomy pancreatic fistula associated hemorrhage (PPFH) is one of the leading lethal complications. Our study was to analyze the risk factors and managements of hemorrhage associated with pancreatic fistula after pancreaticoduodenectomy, and to evaluate treatment options. METHOD: We analyzed 445 patients who underwent pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy and evaluated the relevance between clinical data and PPFH. RESULTS: The incidence of postoperative pancreatic fistula (POPF) was 27.42% (122/445), and the incidence of PPFH was 4.49% (20/445). Among the 20 patients with PPFH, 7 died and 13 were cured. Interventional angiographic therapy was performed for 10 patients and 5 were successfully treated. Relaparotomy was performed for 5 patients and 2 were successfully cured. Univariate logistic regression analysis indicated that several risk factors were related to PPFH: the nature of tumor (carcinoid/low-grade or high-grade malignancy), preoperative day 1 serum prealbumin, preoperative day 1 total bilirubin (TBIL), operative time, blood loss in the operation, operative method (vascular resection and revascularization), postoperative day 3 TBIL, biliary fistula, and the grade of POPF. The multivariate stepwise logistic regression analysis demonstrated that the nature of tumor and the grade of POPF were independently risk factors of PPFH. Receiver operating characteristic curve indicated that preoperative day 1 serum prealbumin level <173 mg/L and postoperative day 3 TBIL level ≥168 μmol/L were the risk factors of PPFH. CONCLUSIONS: The risk of PPFH was found to be increased with high potential malignancy and high grade of POPF. Angiography-embolization is one of the major and effective therapies for PPFH. Extraluminal-intraluminal PPFH is more serious and needs more aggressive treatments.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 537-544 . [Abstract] ( 176 ) [HTML 1KB] [PDF 338KB] ( 399 )

	545	Yang X, Aghajafari P, Goussous N, Patel ST, Cunningham SC
		The “Colonial Wig” pancreaticojejunostomy: zero leaks with a novel technique for reconstruction after pancreaticoduodenectomy
		BACKGROUND: Postoperative pancreatic fistula (POPF) remains common and morbid after pancreaticoduodenectomy (PD). A major advance in the study of POPF is the fistula risk score (FRS). METHODS: We analyzed 48 consecutive patients undergoing PD. The “Colonial Wig” pancreaticojejunostomy (CWPJ) technique was used in the last 22 PDs, we compared 22 CWPJ to 26 conventional PDs. RESULTS: Postoperative morbidity was 49% (27% Clavien grade >2). The median length of hospital stay was 11 days. In the first 26 PDs, the PJ was performed according to standard techniques and the clinically relevant POPF (CR-POPF) rate was 15%, similar to the FRS-predicted rate (14%). In the next 22 PJs, the CWPJ was employed. Although the FRS-predicted rates were similar in these two groups (14% vs 13%), the CR-POPF rate in the CWPJ group was 0 (P=0.052). CONCLUSION: Early experience with the CWPJ is encouraging, and this anastomosis may be a safe and effective way to lower POPF rates.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 545-551 . [Abstract] ( 190 ) [HTML 1KB] [PDF 1034KB] ( 472 )

LETTERS TO THE EDITOR

	552	Mohkam K, Darnis B, Cazauran JB, Rode A, Manichon AF, Ducerf C, ancel B, Mabrut JY
		Polymorphic multiple hepatocellular adenoma including a non-steatotic HNF1α-inactivated variant
		To the Editor: Hepatocellular adenomas (HCAs) consist of benign liver tumors favored by the use of oral contraceptives, which preferentially occur in women.[1, 2] They expose to the risk of hemorrhage (20% of cases) and more rarely, to the risk of malignant transformation (4%-10% of cases).[3, 4] Multiple HCAs, which are defined by the presence of 10 or more HCAs, were first described in 1985 and were initially considered having a worse prognosis than single HCA.[5] However, recent reports have suggested that the risk of complications in patients with multiple HCAs was not related to the number of lesions, but mainly to three other factors: i) tumor size >5 cm for the risk of both hemorrhage and malignant transformation;[3] ii) male gender and iii) β-catenin-mutation for the risk of malignant transformation.[6] Progresses made in terms of genotypic knowledge of HCA have allowed to identify different subtypes of HCA associated with more specific risks of complication.[7] A recent report has suggested that some patients could present with mixed subtypes of HCA.[8] Herein, we report the case of a female patient presenting with polymorphic multiple HCA of three different subtypes, including a very unusual non-steatotic variant of hepatocyte nuclear factor 1 homeobox α (HNF1α)-inactivated HCA mimicking malignant transformation, which was also complicated with repeated episodes of hemorrhage and was finally managed with liver transplantation.
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 552-555 . [Abstract] ( 198 ) [HTML 1KB] [PDF 324KB] ( 641 )

	556	Xie QF, Chen P, Chen XH, Liu JM, Lerut J, Zheng SS
		Gastrointestinal tract post-transplant lymphoproliferative disorder after liver transplantation
		To the Editor: Post-transplant lymphoproliferative disorder (PTLD) is a rare and potentially fatal complication occurring after all types of solid organ transplantation.[1] PTLD accounts for 20% of all de novo post-transplant tumors.[2, 3] The most important risk factors for PTLD are prolonged intense immunosuppression and Epstein-Barr virus (EBV) infection.[4] The gastrointestinal (GI) tract is the most frequently involved site (GI-PTLD), the liver allograft itself can also be involved.[5] As clinical manifestations of PTLD may vary, early diagnosis of PTLD is often difficult.[6, 7]
		Hepatobiliary Pancreat Dis Int. 2017; 16(5): 556-558 . [Abstract] ( 200 ) [HTML 1KB] [PDF 1749KB] ( 422 )

Forgot your password?

Enter your e-mail address to receive an e-mail with your account information.

Submission Guidance

Top cited articles

- Most Cited Hepatobiliary & Pancreatic Diseases International Articles

- Most Downloaded Hepatobiliary & Pancreatic Diseases International Articles

more>>

Top downloaded articles

more>>

Services

Web feed

hbpdint@126.com

hbpdje@zju.edu.cn

Copyright © Official Publication of First Affiliated Hospital
Official Publication of First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
浙ICP备05050873号-1