Serial analysis of JAK2 mutation in a patient who developed essential thrombocythemia after orthotopic liver transplantation

A 52-year-old man developed essential thrombocythemia (ET) with JAK2 V617F mutation after orthotopic liver transplantation (OLT). Retrospective analysis showed that, despite a low platelet count, the JAK2 mutation was already found at presentation 14 months before OLT. The high platelet count that would have been typical of ET might be masked by the cirrhosis-related hypersplenism. Thrombocythemia became obvious after OLT. The patient subsequently developed blastic transformation 12 months afterward, a process probably accelerated by the immunosuppression required for the OLT.

Irreversible aggregation of protein synthesis machinery after focal brain ischemia

Focal brain ischemia leads to a slow type of neuronal death in the penumbra that starts several hours after ischemia and continues to mature for days. During this maturation period, blood flow, cellular ATP and ionic homeostasis are gradually recovered in the penumbral region. In striking contrast, protein synthesis is irreversibly inhibited. This study used a rat focal brain ischemia model to investigate whether or not irreversible translational inhibition is due to abnormal aggregation of translational complex components, i.e. the ribosomes and their associated nascent polypeptides, protein synthesis initiation factors and co-translational chaperones. Under electron microscopy, most rosette-shaped polyribosomes were relatively evenly distributed in the cytoplasm of sham-operated control neurons, but clumped into large abnormal aggregates in penumbral neurons subjected to 2 h of focal ischemia followed by 4 h of reperfusion. The abnormal ribosomal protein aggregation lasted until the onset of delayed neuronal death at 24-48 h of reperfusion after ischemia. Biochemical study further suggested that translational complex components, including small ribosomal subunit protein 6 (S6), large subunit protein 28 (L28), eukaryotic initiation factors 2alpha, 4E and 3eta, and co-translational chaperone heat-shock cognate protein 70 (HSC70) and co-chaperone Hdj1, were all irreversibly clumped into large abnormal protein aggregates after ischemia. Translational complex components were also highly ubiquitinated. This study clearly demonstrates that focal ischemia leads to irreversible aggregation of protein synthesis machinery that contributes to neuronal death after focal brain ischemia.

Wilson's disease: a patient undiagnosed for 18 years

Wilson's disease, an autosomal recessive disorder of copper metabolism, is the most common inherited hepatic disease in Hong Kong. Diagnosis is based on the presence of Kayser-Fleischer rings, typical neurological symptoms, and/or a low serum ceruloplasmin concentration (<0.20 g/L). Early detection and treatment protect patients and their presymptomatic siblings from devastating organ damage. The diagnosis of Wilson's disease may nonetheless be overlooked if only established clinical and laboratory tests are used as diagnostic criteria. We report diagnosis of the disorder using genetic analysis of ATP7B in a presymptomatic sibling who escaped diagnosis during family screening 18 years previously. The patient was 11 months old when family screening was performed following diagnosis of Wilson's disease in an elder sister. The boy was considered to be unaffected on the basis of laboratory results in the expected range: serum copper level, 4.6 micromol/L; serum ceruloplasmin level, 0.16 g/L; and 24-hour urinary copper excretion, 0.14 micromol/day. Molecular analysis of ATP7B was performed; it revealed that the two siblings shared the same compound heterozygous mutations (G943D and 2299delC). We recommend that molecular diagnosis is the only definitive means of diagnosing Wilson's disease in children younger than 1 year.

Subcutaneous Rosai-Dorfman disease: is surgical excision justified?

Rosai-Dorfman disease in soft tissue without nodal disease has been recognized as a distinct clinicopathologic entity. It may represent a diagnostic challenge and the natural history and optimal treatment has not been well clarified. We investigated a patient in whom Rosai-Dorfman disease was confined to the subcutis of the abdominal wall and recurred after incomplete excision. Complete resolution was achieved by wide surgical excision with negative margins. Pathologic examination confirmed the diagnosis of extranodal Rosai-Dorfman disease. The patient is disease-free after 1 year of follow-up. Despite the possibility that spontaneous remission may occur, our results suggest that when anatomically feasible, complete excision can be a treatment option for persistence or recurrence of exclusively extranodal disease. Larger case series and longer follow-up are needed to assess the long-term efficacy in these patients.

Portal vein embolisation prior to extended right-sided hepatic resection

OBJECTIVES

To determine whether preoperative portal vein embolisation improves the operative outcome of patients undergoing extended right-sided hepatic resection for hepatobiliary malignancy.

DESIGN

Prospective non-randomised study.

SETTING

University teaching hospital, Hong Kong.

PATIENTS

Ninety-two patients underwent extended right-sided hepatic resection for hepatobiliary malignancy during a 45-month period (January 2000 to September 2003). Among them, 15 (16%) underwent portal vein embolisation via a percutaneous ipsilateral approach (n=9) or through the ileocolic vein with a mini-laparotomy (n=6). The remaining 77 (84%) patients underwent hepatic resection without portal vein embolisation.

MAIN OUTCOME MEASURES

Operative morbidity and mortality.

RESULTS

Patients undergoing portal vein embolisation were older (69 years vs 55 years; P=0.009), and had significantly worse preoperative renal function (creatinine, 96 micromol/L vs 86 micromol/L; P=0.039) and liver function (bilirubin, 23 micromol/L vs 12 micromol/L; P<0.001). Portal vein embolisation resulted in an increase in the future liver remnant of 9% (interquartile range, 7-13%) of the estimated standard liver volume. The operating time for patients receiving portal vein embolisation was significantly longer (medium, 660 min vs 420 min; P<0.001) with more complicated surgery performed in terms of concomitant caudate lobectomy and hepaticojejunostomy. There was no hospital mortality in patients who underwent portal vein embolisation whereas five without the treatment died (P=0.587). The operative morbidity of patients who underwent portal vein embolisation and those who did not was 20% and 30%, respectively (P=0.543).

CONCLUSIONS

In older patients who have worse preoperative liver and renal functions, portal vein embolisation enhances the possibility to perform extended right-sided hepatic resection for hepatobiliary malignancies with potentially lower operative mortality and morbidity.

Clinico-biochemical prediction of biliary cause of acute pancreatitis in the era of endoscopic ultrasonography

BACKGROUND

Occult biliary stones escape detection on conventional investigations, and clinico-biochemical systems proposed for predicting biliary pancreatitis has low predictive values.

AIM

To evaluate the accuracy of clinico-biochemical parameters for prediction of biliary pancreatitis in patients undergoing endoscopic ultrasonography.

METHODS

Early endoscopic ultrasonography was performed on 139 patients presenting with acute pancreatitis within 24 h of admission. The aetiologies of all patients were determined after complete evaluations, and clinico-biochemical characteristics of patients with a biliary cause (biliary group) and non-biliary causes (non-biliary group) were compared.

RESULTS

Biliary pancreatitis was diagnosed in 107 patients and 32 patients had non-biliary causes. The biliary group belonged to a significantly older age group, had a female predominance, significantly more derangement of liver function and a higher incidence of severe attack of acute pancreatitis. On multivariate analysis, female sex, age >58 years and serum alanine aminotransferase >150 U/L were independent predictive factors for biliary cause of acute pancreatitis. Using these three factors for prediction of biliary cause, the sensitivity was 93% and overall accuracy was 85%.

CONCLUSION

Clinico-biochemical prediction for biliary cause of acute pancreatitis improves in the era of endoscopic ultrasonography with a higher sensitivity and overall accuracy. In centres where endoscopic ultrasonography is inaccessible or local expertise is unavailable, clinico-biochemical prediction of biliary cause of acute pancreatitis may provide a useful alternative in the initial management of this group of patients.

Living donor liver transplantation for hepatitis C related hepatocellular carcinoma in a haemophilia A patient

We report the first case of unrelated living liver transplantation for hepatitis C related hepatocellular carcinoma (HCC) in a Chinese patient with haemophilia A. The development of cirrhosis and HCC was insidious in this patient, who has previously failed interferon treatment despite low viral load and genotype 6a. With factor VIII and novoseven support, there were no operative complications and there was no need for blood transfusion. Postoperative pegulated interferon treatment resulted in viral clearance with no increased cellular rejection. The use of living donors represent a potential life saving therapeutic options for hepatitis C virus related complications in haemophiliac, especially in countries of organ shortage. Careful patient and donor choice, meticulous surgical expertise and proper counselling, however, are prudent requirements.

Different presentation of hepatitis B-related hepatocellular carcinoma in a cohort of 1863 young and old patients - implications for screening

AIM

To compare the clinico-pathological features of hepatitis B virus-related hepatocellular carcinoma in young and old patients.

METHODS

The clinico-pathological characteristics of hepatitis B virus-related hepatocellular carcinoma were compared in 1863 consecutive patients (121 patients, </=40 years; 1742 patients, > 40 years) seen at a single institution over the last 13 years.

RESULTS

Young patients presented more often with pain (P < 0.0001), hepatomegaly (P = 0.01) and ruptured hepatocellular carcinoma (P = 0.02), whereas old patients presented with ankle oedema (P = 0.001), ascites (P = 0.002) and by routine screening (P = 0.035). Liver function, Child-Pugh grading and indocyanine green test were better preserved in young patients. They also had a higher alpha-foetoprotein concentration (P = 0.001), larger tumour size (P = 0.001) and more frequent metastasis (P = 0.008), but a similar surgical resection rate (33.6% vs. 28%), to old patients. There was no difference between the two groups in the overall post-resection survival rate, but there was a shorter survival in young patients with unresectable disease (3.6 months vs. 4.6 months, P = 0.004). Young patients with hepatocellular carcinoma often show a later presentation, but a higher resectability rate and similar survival rates, than old patients. The screening programme should include young hepatitis B virus carriers, even in the absence of cirrhosis.

The effect of oxidants on 2-MIB concentration with the presence of cyanobacteria

In this study, the effect of three oxidants, sodium hypochlorite, potassium permanganate, and ozone, were tested for the removal of 2-MIB with presence of cyanobacteria. Algae in water samples from the source water of Feng-Shen waterworks (FSW), Taiwan were cultivated at 30 degrees C with continuous light at an intensity between 2,500 and 3,400 lux. During the cultivating process, water samples were analyzed for nutrients, light absorbance at 665 nm (A665), and 2-MIB concentration. The 2-MIB concentrations within the incubated samples increased to as high as 1,000 ng/L to 2,000 ng/L, although no extra nutrients were added to the raw water. After 2 to 3 days incubation, the intracellular 2-MIB concentration was as high as 70% of the total 2-MIB in the samples. The algae that developed were mainly cyanobateria, and more than 90% belonged to the Genus Oscillatorias. An almost 100% removal of both 2-MIB and geosmin in the raw water was observed after ozonation for 10 minutes at a dosing rate of 0.91 mg/l-min. Chlorine and permanganate were much less effective, both removing only about 11% of the 2-MIB within 60 minutes at oxidant concentration of 10 mg/l. Oxidation of the cultivated samples showed that chlorine and permanganate may damage algae cells causing them to release intracellular 2-MIB. During the 60 minutes of reaction time, the total 2-MIB concentrations (intracellular plus dissolved) varied by no more than 10%, however, the ratios between dissolved and total 2-MIB concentrations increased. Two effects of ozonation on the 2-MIB concentration in the cultivated samples were observed when the algae were young, namely 2-MIB release from damaged cells and 2-MIB oxidization. The rates of 2-MIB release and 2-MIB destruction were similar. However, old algae cells were more easily damaged. As a result, intracellular 2-MIB was released faster, and the soluble 2-MIB was destroyed more quickly by ozonation.

Potential role for platelet apheresis for post-liver transplant thrombocytosis complicating portal vein thrombosis

Except for patients with underlying myeloproliferative diseases (MPD), thrombocytosis is rarely encountered in cirrhotic patients after liver transplantation. Although the long-term control of primary thrombocytosis is important for the prevention of graft thrombosis in MPD patients, the threshold for intervention and best mode for the control of persistent reactive thrombocytosis after liver transplantation is unclear. We present two patients with extreme reactive thrombocytosis (over 1,000 x 10(9)/l) due to intra-abdominal sepsis after liver transplantation. Furthermore, both patients suffered from bleeding problems as well as ongoing venous thrombosis of the graft. Rapid control of the platelet count was achieved using platelet apheresis. The use of cell separation procedures may be a relatively rapid, reversible, and reasonably safe way to control platelet counts peri-operatively in liver transplant recipients.

Emergency aortic stent grafting for traumatic rupture of the thoracic aorta

OBJECTIVE

To investigate the role of aortic stent grafting in emergency treatment of traumatic rupture of the descending thoracic aorta in patients with multiple injuries.

DESIGN

Retrospective study.

SETTING

Cardiothoracic surgery facility of a tertiary referral hospital, Hong Kong.

PATIENTS

Between September 2001 and September 2002, four patients who had sustained a blunt injury to the chest after high-speed deceleration injury were recruited. Three patients were treated with stent grafting because concomitant head injury and multiple other injuries precluded the use of open thoracic surgery. One patient had no head injury and was offered stent grafting as a less invasive treatment.

INTERVENTION

The pseudoaneurysm was covered with an aortic stent graft under fluoroscopic and angiographic guidance.

MAIN OUTCOME MEASURES

Technical success of treatment, complications, and treatment outcome.

RESULTS

Three patients recovered and were discharged from hospital. The computed tomography scan at 3 months to 6 months after surgery showed resolution of the pseudoaneurysm. The final patient was still in the hospital. Follow-up computed tomography 2 weeks later showed exclusion of the pseudoaneurysm. There was one external iliac artery thrombosis on the side of femoral arteriotomy, which was recanalised with thrombectomy. There was another unintentional partial coverage of the left subclavian artery, which was asymptomatic. No other major complication was present and there was no paraplegia after the stent grafting.

CONCLUSION

Aortic stent graft is useful for emergency treatment of descending thoracic aortic injury. In the short term, it causes less morbidity and mortality than does open surgery, and can be life-saving when there is no surgical alternative. The long-term effect is still unknown.

Red blood cell alloantibodies and liver transplantation in Chinese patients

BACKGROUND

Red blood cell (RBC) alloantibodies are present in up to 14% of white recipients of liver transplants and can cause severe delayed hemolysis.

METHODS

A retrospective survey showed 17 cases (8.8%) of RBC alloantibodies in 192 consecutive Chinese recipients of liver transplants compared with a background hospital incidence of 3.7%.

RESULTS

The spectrum of RBC alloantibodies in Chinese patients was different than in white patients, with no anti-D or anti-K antibodies but a significant incidence of anti-Mi (29%) antibodies. There was a significantly increased incidence of transfusions in RBC alloantibody positive cases. Delayed hemolysis also resulted in higher day-7 bilirubin levels. A total of 7 to 86 antigen-positive units were issued in five RBC alloantibody cases, including three early deaths. Seven cases in the RBC alloantibody negative group, but none in the positive group, were salvaged by regraft.

CONCLUSIONS

Blood banks servicing transplant centers should be aware of ethnic patterns in RBC alloantibodies. Delayed hemolysis may jeopardize patient survival as the result of difficult postoperative stabilization, especially in cases requiring massive transfusion.

Red blood cell alloantibodies and liver transplantation in Chinese patients

Red blood cell (RBC) alloantibodies are present in up to 14% of white recipients of liver transplants and can cause severe delayed hemolysis. A retrospective survey showed 17 cases (8.8%) of RBC alloantibodies in 192 consecutive Chinese recipients of liver transplants, compared with a 3.7% background hospital incidence. The spectrum of RBC alloantibodies was different from that in white recipients, with no anti-D or anti-K antibodies but with a significant incidence of anti-Mi (29%) antibodies. There was significantly increased transfusion in RBC alloantibody positive cases. Delayed hemolysis also resulted in higher day-7 bilirubin levels. A total of 7 to 86 antigen-positive units were issued in five RBC alloantibody cases, including three early deaths. Seven cases in the RBC alloantibody negative group, but none in the positive group, were salvaged by regraft. Blood banks servicing transplant centers should be aware of ethnic patterns in RBC alloantibodies. Delayed hemolysis may jeopardize patient survival as a result of difficult postoperative stabilization, especially in cases requiring massive transfusion.

Outcome for Hong Kong residents undergoing cadaveric liver transplantation in mainland China

OBJECTIVE

To review the outcome for Hong Kong residents undergoing cadaveric liver transplantation in mainland China.

DESIGN

Retrospective study.

SETTING

Liver Transplant Centre, university teaching hospital, Hong Kong.

SUBJECTS AND METHODS

A retrospective review of medical records was undertaken for patients at Queen Mary Hospital who underwent cadaveric liver transplantation in China between 1 January 1997 and 31 December 2001.

RESULTS

Fifteen patients from Queen Mary Hospital underwent cadaveric liver transplantation in China during the study period. Eleven were men and four were women. Their mean age was 51 years. Disease indications included hepatitis B-related liver cirrhosis (n=7), hepatitis B-related liver cirrhosis with hepatocellular carcinoma (n=5), hepatitis C-related liver cirrhosis (n=1), hepatitis C-related liver cirrhosis with hepatocellular carcinoma (n=1), and polycystic liver and kidney disease (n=1). Nine patients were already waiting for liver transplantation at Queen Mary Hospital, and two of the nine patients were on the 'urgent' list. The overall survival rate was 80.0% at 6 months and 73.3% at 12 months. There were four (27%) deaths, two of which occurred in China. Of the 11 surviving patients, nine (82%) developed complications. Nineteen complications were seen in the 13 patients who were managed in Hong Kong following their return from China. Infective and biliary complications accounted for 58% and 26% of complications, respectively. Major complications necessitated prolonged hospitalisation for four patients and two required further laparotomy.

CONCLUSION

Although cadaveric liver transplantation in China is an option for Hong Kong residents, patients and clinicians should be aware of the possible outcomes and resource implications.

Genetics of familial amyloidotic polyneuropathy in a Hong Kong Chinese kindred

Familial amyloidotic polyneuropathy type 1 (FAP1, MIM176300) is an autosomal dominant disease caused by mutations in the transthyretin (TTR) gene. An extended Chinese kindred of FAP1 was first reported in Hong Kong in 1989, three of the four histologically proven subjects have deceased. TTR gene mutations were not studied then. A DNA-based diagnosis was performed on FAP1 by restriction analysis and direct DNA sequencing was carried out on a symptomatic member of this family who had undergone a liver transplantation. It showed a substitution of thymine by cytosine in the second base of codon 30 in exon 2 of the TTR gene, with the creation of a novel HhaI restriction endonuclease site. Valine is substituted by alanine (V30A) in the mutant TTR. Both restriction analysis and direct sequencing revealed the same mutation in one of the two asymptomatic siblings. This mutation was first reported in a FAP1 family of German descent.

Emergency living related liver transplantation for fulminant reactivation of hepatitis B virus after unrelated marrow transplantation

We report a unique case of emergency living related donor orthotopic liver transplantation (OLT) for late fulminant reactivation of hepatitis B virus (HBV) after matched unrelated bone marrow transplantation (BMT) for chronic myeloid leukemia (CML). Cessation of lamivudine after BMT for HBV positive patients may carry risks of late fatal HBV reactivation. Similar to fulminant HBV reactivation in the general population, OLT under resumption of lamivudine can be life saving. In our case, concomitantly molecular relapse of CML at the time of liver failure was also cleared by OLT, possibly via a 'liver-graft vs. leukemia' effect. Liver rejection (graft vs. graft disease) was mild due to inherent immunocompromise of the marrow graft. Hence BMT recipients in stable remission should not be denied the opportunity for life-saving solid organ transplantation. A choice of marrow and liver donors with innate HBV immunity may be needed to give the additional advantage of long-term HBV clearance.

Immunoprofile of cervical and endometrial adenocarcinomas using a tissue microarray

Adenocarcinomas of the uterine cervix show a wide range of morphological features, and can be confused with endometrial adenocarcinoma in biopsy or curetting specimens. The objective of this study was to use tissue microarray technology to evaluate the immunoprofile of a large set of uterine adenocarcinomas with an extended panel of antibodies, comparing the profile of primary cervical and endometrial adenocarcinomas. A tissue microarray was constructed using paraffin-embedded, formalin-fixed tissues from 141 hysterectomy specimens. Duplicate 0.6-mm cores were obtained from 57 cervical adenocarcinomas (16 in situ and 41 invasive) and 84 endometrial adenocarcinomas. Tissue array sections were immunostained with 21 commercially available antibodies [B72.3, CD 99, carcinoembryonic antigen (CEA), c-kit, pancytokeratin, CK 5/6, CK 7, CK8/18, CK19, CK 20, CK 22, EMA, estrogen receptor (ER), KP-1, melan-A, p53, PLAP, S-100, synaptophysin, TTF-1, and vimentin] utilizing the avidin-biotin (ABC) technique. Hierarchical clustering analysis of the tumors was done based on the immunostaining results. Only ER ( P<0.001), CEA ( P=0.04), vimentin ( P<0.001), and CK 8/18 ( P=0.002) showed a significantly different frequency of positivity in endometrial relative to cervical adenocarcinomas. ER, vimentin, and CK 8/18 were more likely to be expressed in endometrial adenocarcinomas, while cervical adenocarcinomas more frequently expressed CEA. We were able to identify immunoprofiles that were highly specific for endocervical adenocarcinoma (ER(-), vimentin(-), CK 8/18(-), CEA(+)) or endometrial adenocarcinoma (ER(+), vimentin(+), CK 8/18(+), CEA(-)), but most tumors showed an intermediate, non-specific immunophenotype. Hierarchical clustering analysis was useful in the interpretation of these intermediate immunophenotypes. Papillary serous adenocarcinoma of the endometrium was less likely to express vimentin ( P=0.002) than endometrioid carcinoma of the endometrium.

Solid-phase microextraction from small volumes of sample in a glass capillary

A new sampling method is proposed for solid-phase microextraction (SPME), in which the extraction is carried out in a glass capillary containing a few microliters of sample. When an adsorption-type fiber is used for SPME, the equilibrium between aqueous sample and coating can be described by a Langmuir isotherm. Since the total amount of analytes and coexisting substances stays at a low level in a small volume of sample, the linear concentration range of analytes will be extended for SPME to be applied in quantification and the interference caused by sample matrix will be reduced. In addition, sampling in a capillary has a short diffusion distance and extraction equilibrium is established in 5-10 min. It is important in clinical analysis and therapeutic drug monitoring to be able to analyse sample volumes of samples. The feasibility of the new sampling method is demonstrated by the extractions of p-hydroxybenzaldehyde and a synthetic solution containing 1-naphthol, paeonol and 1-naphthylamine.

A simple method for DNA extraction from marine bacteria that produce extracellular materials

We present a simple method for extracting DNA from the marine bacteria Hahella chejuensis, a Streptomyces sp., and a Cytophaga sp. Previously, DNA purification from these strains was hindered by the presence of extracellular materials. In our extraction method, the marine bacteria are lysed by freezing and grinding in liquid nitrogen, and treated with SDS. The extracted DNA is purified using a phenol/chloroform mixture, and precipitated in isopropanol. The extracted DNA is of high quality and suitable for molecular analyses, such as PCR, restriction enzyme digestion, genomic DNA blot hybridization, and genomic DNA library construction. We used this method to extract genomic DNA from several other marine bacteria. Our method is a reproducible, simple, and rapid technique for routine DNA extractions from marine bacteria. Furthermore, the low cost of this method makes it attractive for large-scale studies.

Right lobe living donor liver transplantation with or without venovenous bypass

BACKGROUND

Venovenous bypass was considered necessary to maintain haemodynamic stability and avoid splanchnic and retroperitoneal congestion during the anhepatic phase of liver transplantation. It was essential for right lobe living donor liver transplantation (LDLT) in which the inferior vena cava needed to be cross-clamped to construct wide and short hepatic vein anastomoses. However, many complications related to venovenous bypass have been reported. This study aimed to determine whether venovenous bypass was necessary for right lobe LDLT.

METHODS

Between June 1996 and June 2001, 72 patients underwent right lobe LDLT. The outcomes for the first 29 patients who had venovenous bypass during the operation were compared with those of the remaining 43 patients who did not have venovenous bypass. In patients without bypass, blood pressure was maintained during the anhepatic phase by boluses of fluid infusion and vasopressors.

RESULTS

Compared with patients undergoing operation without venovenous bypass, patients who had venovenous bypass required significantly more blood, fresh frozen plasma and platelet infusion, and had a lower body temperature; their postoperative hepatic and renal function in the first week was worse than that in patients who did not have a bypass. The time to tracheal extubation was longer and the incidence of reintubation for ventilatory support was higher with venovenous bypass. Six of the 29 patients with venovenous bypass died in hospital, compared with two of the 43 patients without a bypass (P = 0.05). By multivariate analysis, the lowest body temperature during the transplant operation was the most significant factor that determined hospital death.

CONCLUSION

Venovenous bypass is not necessary and is probably harmful to patients undergoing right lobe LDLT, and should therefore be avoided.

Hepatic resection for colorectal liver metastases: prospective study

OBJECTIVE

To assess the operative and long-term survival outcomes of hepatic resection for colorectal liver metastases during an 11-year period in a tertiary referral centre in Hong Kong.

DESIGN

Prospective study.

SETTING

University teaching hospital, Hong Kong.

SUBJECTS AND METHODS

Between January 1989 and December 1999, 72 patients underwent hepatic resection for colorectal liver metastases. Clinical, pathological, and outcome data were prospectively collected and analysed. Factors affecting long-term survival were also evaluated.

RESULTS

Twenty-five (34.7%) patients were found to have synchronous hepatic metastasis at the time of colorectal resection. Fifty-two (72.2%) patients underwent major hepatic resection. The operative morbidity and hospital mortality rates were 19% and 4%, respectively. The 5-year survival rate after hepatectomy was 31.9%. The median disease-free survival and median overall cumulative survival were 18.5 months and 30.8 months, respectively. On multivariate analysis, a high preoperative serum carcinoembryonic antigen level (>200 ng/mL) and tumour involvement of the resection margin at histology were the two independent risk factors that adversely affected survival outcome.

CONCLUSION

Hepatic resection for colorectal liver metastases can be performed safely, with minimal operative mortality and acceptable morbidity, and results in satisfactory survival. High preoperative serum carcinoembryonic antigen level and histological involvement of resection margin by cancer adversely affect the survival outcome.

Ten-year experience with liver transplantation at Queen Mary Hospital: retrospective study

OBJECTIVE

To report the experience with liver transplantation at the Queen Mary Hospital from 1991 to 2000.

DESIGN

Retrospective study.

SETTING

Liver transplant centre of a University teaching hospital, Hong Kong.

PATIENTS

One hundred and forty-eight patients (127 adults and 21 children) who underwent a total of 155 liver transplants using 75 cadaver grafts (full-size, 67; reduced-size, 5; split, 3) and 80 living donor grafts (left lateral segment, 15; left lobe, 6; right lobe, 59) from October 1991 to December 2000 were reviewed.

MAIN OUTCOME MEASURES

Graft and patient survival rate.

RESULTS

The most common disease indications for liver transplantation were chronic hepatitis B-related liver disease (n=74) in adults and biliary atresia (n=14) in children. Eighteen patients had hepatocellular carcinoma. Forty-eight (31%) liver transplants (three ABO-incompatible) were performed in high-urgency situations for patients requiring intensive care. The proportion of living donor liver transplants was 47.7% in adults and 73.9% in children. The overall 1-year and 5-year patient survival rates were 82% and 77%, respectively. The survival of high-risk recipients, such as those with fulminant hepatic failure (80%), chronic hepatitis B (81%), or hepatocellular carcinoma (94%), was not inferior to that of other patients.

CONCLUSION

Over the last decade, the promotion of (cadaver) organ donation through public education coupled with innovative techniques in living donor liver transplantation have enabled a liver transplantation programme to be established in Hong Kong with gratifying results.

Post-transplantation lymphoproliferative disease in Chinese: the Queen Mary Hospital experience in Hong Kong

Post-transplantation lymphoproliferative disease (PTLD) is an unique iatrogenic complication after bone marrow transplantation (BMT) and solid organ transplantation (SOTx). The pattern of EBV related lymphoma in Chinese is different from Caucasians. We surveyed the incidence, clinical and pathological spectrum of PTLD among 541 cases of allogeneic BMT, 145 cases of renal transplant, 35 cases of heart/lung transplantation and 146 cases of orthotopic liver transplantation (OLT). From 1994 to 2001, 13 consecutive cases of PTLD were diagnosed, ranging from disseminated NK cell lymphoma to localized plasmacytoma. Both donor and recipient derived PTLD was documented. Disease was often heralded by cytomegaloviral disease and antithymocyte globulin (ATG) usage. Two cases were diagnosed post-mortem, and six patients died of PTLD at a median of 3 months. Complete and partial remission was only achieved in 3 and 2 cases, respectively, despite a range of treatment (reduced immunosuppression, explantation, radiotherapy, combination chemotherapy, donor lymphocytes, autologous marrow infusion and rituximab). Most responding patients died subsequently of rejection, infection and graft versus host disease (GVHD). The incidence of PTLD is not increased in Chinese patients. However, some patients may be at increased risk, especially mismatched allogeneic BMT, parental OLT (especially involving young infants) and heavy ATG exposure.