Screening, Surveillance, and Management of Hepatocellular Carcinoma During the COVID-19 Pandemic: a Narrative Review

PURPOSE

The COVID-19 pandemic has been a burden to the global community as a whole but the healthcare community had bore the brunt of it. The pandemic resulted in policy changes that interfered with effective healthcare delivery. The healthcare community attempted to cope with the pandemic by triaging and prioritizing emergency conditions especially COVID related, ahead of elective conditions like cancer care. There was also fear that patients with cancer were at an increased risk of sever COVID-19 with increased mortality. Hepatocellular carcinoma (HCC) was also affected by these policies.

METHODS

We reviewed the modified measures adopted in screening, surveillance, and management of HCC during the pandemic using PubMed, Medline, Index Medicus, EMBASE, SCOPUS, and Google Scholar databases.

RESULT

The main modification in surveillance and screening for HCC during the pandemic includes limiting the surveillance to those with very high risk of HCC. The interval between surveillan was also delayed by few months in some cases. The adoption of teleconferencing for multidisciplinary team meetings and patient consultation is one of the highlights of this pandemic all in an effort to reduce contact and spread of the virus. The treatment of early-stage HCC was also modified as needed. The role of ablative therapy in the management of early HCC was very prominent during the pandemic as the surgical therapy was significantly affected by the lacks of ventilators and intensive care unit space resulting from the pandemic. Transplantation, especially living donor liver transplantation, was suspended in few centers because of the risk of infection to the living donors.

CONCLUSION

As we gradually recover from the pandemic, we should prepare for the fallout from the pandemic as we may encounter increased presentation of those patients deferred from screening during the pandemic.

Is fundus first laparoscopic cholecystectomy a better option than conventional laparoscopic cholecystectomy for difficult cholecystectomy? A systematic review and meta-analysis

The gallstone disease prevalence is up to 27% in the general adult population. Though most of the patients are asymptomatic, about 1-4% of these patients became symptomatic every year and will require treatment. Fundus first laparoscopic cholecystectomy (FFLC) was first reported by Cooperman in 1990 when he utilized the approach to safely perform LC for patients with acute cholecystitis and dense adhesion around the calot's triangle which precluded safe dissection. Some surgeons reported that the FFLC may be quicker than the traditional dissection starting at the Calot's triangle, although no randomized trial has been undertaken to confirm that. We aim to perform this systematic review and meta-analysis to compare outcome of fundal first laparoscopic cholecystectomy with conventional laparoscopic cholecystectomy. Three reviewers independently searched the Pubmed, medline, google schoolar, Cochrane library and Embase databases for prospective or retrospective articles comparing outcomes of fundus first LC and conventional LC. The search terms were "retrograde cholecystectomy", "antegrade cholecystectomy", "fundus first cholecystectomy", "fundus down cholecystectomy", and "dome down cholecystectomy". Studies were selected based on predetermined criteria and data were extracted from the study for meta-analysis. Twelve studies were included for meta-analysis. Our analysis revealed that FFLC is associated with less conversion to open surgery, less time of surgery, less risk of bile duct injuries and shorter duration of hospital stay compared conventional cholecystectomy in patients with difficult cholecystectomy. In conclusion, fundus first laparoscopic cholecystectomy is a safer alternative to conventional laparoscopic cholecystectomy in patients with difficult cholecystectomy.

Clinical presentation, management, screening and surveillance for colorectal cancer during the COVID-19 pandemic

Management of colorectal cancer (CRC) was severely affected by the changes implemented during the pandemic, and this resulted in delayed elective presentation, increased emergency presentation, reduced screening and delayed definitive therapy. This review was conducted to analyze the impact of the coronavirus disease 2019 (COVID-19) pandemic on management of CRC and to identify the changes made in order to adapt to the pandemic. We performed a literature search in PubMed, Medline, Index Medicus, EMBASE, SCOPUS, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and Google Scholar using the following keywords in various combinations: Colorectal cancer, elective surgery, emergency surgery, stage upgrading, screening, surveillance and the COVID-19 pandemic. Only studies published in English were included. To curtail the spread of COVID-19 infection, there were modifications made in the management of CRC. Screening was limited to high risk individuals, and the screening tests of choice during the pandemic were fecal occult blood test, fecal immunochemical test and stool DNA testing. The use of capsule colonoscopy and open access colonoscopy was also encouraged. Blood-based tests like serum methylated septin 9 were also encouraged for screening of CRC during the pandemic. The presentation of CRC was also affected by the pandemic with more patients presenting with emergencies like obstruction and perforation. Stage migration was also observed during the pandemic with more patients presenting with more advanced tumors. The operative therapy of CRC was altered by the pandemic as more emergencies surgeries were done, which may require exteriorization by stoma. This was to reduce the morbidity associated with anastomosis and encourage early discharge from the hospital. There was also an initial reduction in laparoscopic surgical procedures due to the fear of aerosols and COVID-19 infection. As we gradually come out of the pandemic, we should remember the lessons learned and continue to apply them even after the pandemic passes.

Effect of COVID-19 Pandemic on Patients Who Have Undergone Liver Transplantation Because of Hepatocellular Carcinoma

BACKGROUND AND AIM

Many clinical studies have shown that the COVID-19 case fatality rate is higher in older patients, those with comorbidities, those with immunosuppressive conditions, and those who stay in the intensive care unit. This study aims to evaluate the clinical outcomes of 66 liver transplant (LT) patients with primary liver cancer who were exposed to COVID-19 infection.

METHODS

Demographic and clinical data of 66 patients with primary liver cancer (hepatocellular carcinoma = 64, hepatoblastoma = 1, cholangiocarcinoma = 1) who underwent LT in our institute and were exposed to COVID-19 infection between March 2020 and November 2021 were analyzed in this cross-sectional study. The following data of the patients were recorded: age, sex, body mass index (kg/m2), blood group, underlying primary liver disease, smoking, tumor characteristics, post-transplant immunosuppressive agents, COVID-19 symptoms, hospitalization, intensive care unit stay, intubation, and other clinical features.

RESULTS

There were 55 (83.3%) male and 11 (16.7%) female patients, with a median age of 58 years. Sixty-four patients were exposed to COVID-19 only once, whereas the remaining 2 patients were exposed 2 and 4 times, respectively. After exposure to COVID-19, it was determined that 37 patients used antiviral drugs, 25 were hospitalized, 9 were followed in the intensive care unit, and 3 were intubated. One intubated patient was under hospital follow-up because of biliary complications before exposure to COVID-19, and this patient died from sepsis.

CONCLUSION

The low mortality rate of LT patients with primary liver cancer exposed to COVID-19 infection can be attributed to background immunosuppression that prevents cytokine storm. However, it is appropriate to support this study with multicenter studies to make strong comments on this issue.

Histopathological Features of Gallbladder Specimens Obtained From Liver Recipients

BACKGROUND

To evaluate the histopathological features of gallbladder specimens obtained from liver transplantation (LT) recipients and to find the correlation between these findings with the clinical features of patients.

METHODS

The 1985 patients who underwent LT in our institute between March 2002 and January 2021 and whose data regarding pathologic analysis of gallbladder could retrospectively be obtained were included in the study. The data of the patients including age, gender, the reason for LT (fulminant or nonfulminant), presence of ascites, macroscopic characteristics of gallbladder (the length, diameter, and wall thickness), and microscopic findings were all obtained and analyzed in the present study.

RESULTS

A total of 1985 patients (men = 1300 and women = 685) with a median age of 39.4 years were included in this study. LT was performed in 249 patients because of fulminant liver failure, and abdominal ascites were detected in 933 patients during LT. There were statistical differences in terms of age (P < .001), gallbladder length (P < .001). and width (P < .001) among the both gender, but there was no difference in terms of histopathologic characteristics and presence of gallstones. On the other hand, there were significant differences in terms of age (P < .001), gallbladder length (P < .001), width (P < .001), wall thickness (P = .021), presence of gallstones (P < .001), and histopathologic characteristics (P < .001) between the patients with fulminant and nonfulminant liver failure etiologies. Similar results were obtained when characteristics of patients with and without ascites were compared.

CONCLUSIONS

This the first study analyzing the histopathological analysis of gallbladder specimens in LT recipients. Chronic liver disease, presence of ascites and gender are the factors affecting the macroscopic and microscopic features of the gallbladder.

Early outcome of machine perfusion vs static cold storage of liver graft: A systemic review and meta-analysis of randomized controlled trials

The use of marginal grafts is very challenging and is associated with post-reperfusion syndrome and early allograft dysfunction. The outcomes of machine perfusion for the preservation of marginal grafts have been compared with that of static cold storage, with studies reporting a reduced risk of ischemic cholangiopathy and graft loss. We performed this systematic review and meta-analysis of randomized controlled trials (RCTs) comparing outcomes of machine perfusion of liver grafts to static cold storage (SCS) of liver grafts during liver transplantation. Two independent researchers thoroughly searched for literature in the following databases: PubMed (Medline), Cochrane Central Register of Controlled Studies (CENTRAL), clinical trial registry, ResearchGate, Google Scholar, and Scopus (ELSEVIER) databases (last search: November 2023). The search terms used were: "dynamic perfusion," "normothermic perfusion," "hypothermic perfusion," "liver transplantation," "static cold storage," "NMP," "HOPE," "extended criteria grafts," "marginal grafts," "RCTs," "randomized controlled trials," "warm ischemia," and "cold ischemia." Eight RCTs published between 2019 and 2023 were included in the data synthesis and meta-analysis. The primary outcome considered was the overall incidence of early allograft dysfunction (EAD) between the two methods of graft perfusion after liver transplantation. The secondary outcome considered was the rate of retransplantation. Our meta-analysis revealed that SCS is associated with more EAD when compared with machine perfusion, with a p-value of <0.00001. We also found that the rate of retransplantation is higher among patients who received a liver preserved by SCS, with a p-value of 0.02. The use of machine perfusion in the preservation of liver grafts showed a significant reduction in early allograft dysfunction and retransplantation.

Effect of ursodeoxycholic acid on liver regeneration capacity after living donor hepatectomy: a prospective, randomized, double-blind clinical trial

OBJECTIVE

Ursodeoxycholic acid (UDCA) has multiple hepatoprotective activities: it modifies the bile acid pool, decreases levels of endogenous, hydrophobic bile acids while increasing the proportion of nontoxic hydrophilic bile acids. It also has cytoprotective, antiapoptotic, and immunomodulatory properties. The aim of this study was to analyze the effect of postoperative administration of UDCA on liver regeneration capacity.

PATIENTS AND METHODS

This is a single-center, prospective, randomized, double-blind study that was carried out in our Liver transplant Institute. Sixty living liver donors (LLDs) who underwent right lobe living donor hepatectomy were divided into two groups using computer-generated random numbers: one group received oral UDCA 500 mg 12 hourly for 7 days (UDCA group; n=30) from the first postoperative day (POD) and the other did not receive UDCA (non-UDCA group; n=30). Both groups were compared in terms of the following parameters: clinical and demographic parameters, liver enzymes (ALT, AST, ALP, GGT, total bilirubin, direct Bilirubin), and INR.

RESULTS

The median ages in the UDCA and non-UDCA were 31 years (95% CI for median: 26-38) and 24 years (95% CI for median: 23-29), respectively. Liver function tests showed significant differences at various times within the first seven PODs. The INR was lower in UDCA group patients on POD3 and POD4. However, GGT was significantly lower on POD6 and POD7 for the UDCA group. Total bilirubin was also significantly lower on POD3 for the UDCA group patients, but ALP was lower all from POD1 to POD7. A significant difference was also observed in AST on POD3, POD5 and POD6.

CONCLUSIONS

Postoperative administration of oral UDCA significantly improves liver function tests and INR among LLDs.

Ursodeoxycholic Acid Prophylaxis and the Reduction of Gallstone Formation After Bariatric Surgery: An Updated Meta-Analysis of Randomized Controlled Trials

Gallstone formation following bariatric surgery poses a significant clinical concern, prompting various preventive strategies, including ursodeoxycholic acid (UDCA) prophylaxis. This systematic review and meta-analysis aimed to assess the efficacy of UDCA in preventing gallstone formation after bariatric surgery. A comprehensive literature search was conducted in major databases up to September 2023, identifying 12 randomized controlled trials (RCTs) meeting the inclusion criteria. The studies, spanning from 1993 to 2022, involved 2,767 patients who underwent diverse bariatric procedures. The primary outcome was the overall incidence of cholelithiasis, with secondary outcomes encompassing gallstone occurrences at three, six, and 12 months; symptomatic cholelithiasis; and rates of cholecystectomy. The Cochrane risk-of-bias tool was utilized for evaluating study quality, and statistical analyses were conducted using the RevMan software (Cochrane Collaboration, London, UK). Patients receiving UDCA demonstrated a significantly lower overall incidence of gallstones post-bariatric surgery (risk ratio [RR] 0.13; P < 0.0001). Subgroup analyses confirmed reduced gallstone incidence at three months (P = 0.04), six months (P < 0.00001), and one year (P < 0.00001) with UDCA prophylaxis. Symptomatic cholelithiasis incidence was also lower in the UDCA group (RR 5.70; P < 0.00001), and cholecystectomy rates were significantly reduced (RR 3.05; P = 0.002). This meta-analysis supports the efficacy of UDCA prophylaxis in preventing gallstone formation after bariatric surgery. The findings suggest that UDCA administration not only lowers overall gallstone incidence but also reduces the occurrence of symptomatic cholelithiasis and mitigates the need for cholecystectomy. However, caution is warranted due to heterogeneity, diverse surgical procedures, and limited long-term follow-up in the included studies. Further research with standardized protocols and extended observational periods is recommended to strengthen the evidence base and guide clinical practice.

Outcome of split liver transplantation vs living donor liver transplantation: A systematic review and meta-analysis

BACKGROUND

The outcomes of liver transplantation (LT) from different grafts have been studied individually and in combination, but the reports were conflicting with some researchers finding no difference in both short-term and long-term outcomes between the deceased donor split LT (DD-SLT) and living donor LT (LDLT).

AIM

To compare the outcomes of DD-SLT and LDLT we performed this systematic review and meta-analysis.

METHODS

This systematic review was performed in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. The following databases were searched for articles comparing outcomes of DD-SLT and LDLT: PubMed; Google Scholar; Embase; Cochrane Central Register of Controlled Trials; the Cochrane Database of Systematic Reviews; and Reference Citation Analysis (https://www.referencecitationanalysis.com/). The search terms used were: "liver transplantation;" "liver transplant;" "split liver transplant;" "living donor liver transplant;" "partial liver transplant;" "partial liver graft;" "ex vivo splitting;" and "in vivo splitting."

RESULTS

Ten studies were included for the data synthesis and meta-analysis. There were a total of 4836 patients. The overall survival rate at 1 year, 3 years and 5 years was superior in patients that received LDLT compared to DD-SLT. At 1 year, the hazard ratios was 1.44 (95% confidence interval: 1.16-1.78; P = 0.001). The graft survival rate at 3 years and 5 years was superior in the LDLT group (3 year hazard ratio: 1.28; 95% confidence interval: 1.01-1.63; P = 0.04).

CONCLUSION

This meta-analysis showed that LDLT has better graft survival and overall survival when compared to DD-SLT.

Isolated Roux-en-Y versus single loop pancreaticojejunal reconstruction after pancreaticoduodenectomy - a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Pancreaticoduodenectomy is a complex intra-abdominal operation used for the treatment of benign and malignant disease of the pancreatic head or periampullary region. Despite developments in surgical techniques, pancreaticoduodenectomy is still associated with high rate of postoperative complications. We performed this systematic review and meta-analysis to compare the surgical outcomes of isolated Roux-en-Y pancreaticojejunostomy (IRYPJ), and conventional pancreaticojejunostomy(CPJ).

METHODS

We performed a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. We searched the following electronic databases - PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Clinical-Trials.gov. Published trials comparing the efficacy and safety of IRYPJ and CPJ after pancreaticoduodenectomy were evaluated. The search terms were "pancreaticoduodenectomy," "Whipple," "pylorus-preserving pancreaticoduodenectomy," "pancreaticojejunostomy," "Roux-en-Y," and "isolated Roux loop pancreaticojejunostomy." Only randomised controlled trials comparing outcome of IRYPJ and CPJ after pancreaticoduodenectomy were included. The analysed outcome measures were postoperative pancreatic fistula (POPF), clinically relevant POPF (CR-POPF), bile leak and delayed gastric emptying (DGE).

RESULTS

The initial search yielded 342 results but only four randomised control trials fulfilled the inclusion criteria and were included for data synthesis and meta-analysis. Meta-analysis of POPF revealed that IRYPJ is associated with less POPF compared to CPJ but the difference was not statistically significant (risk ratio = 0.58, p = 0.56). A similar finding was also observed with CR-POPF (risk ratio = 0.17, p = 0.87) and DGE (risk ratio = 0.74, p = 0.46).

CONCLUSION

Isolated Roux-en-Y pancreaticojejunostomy is not associated with a superior outcome when compared to CPJ.

Evaluation of Bone Mineral Metabolism After Liver Transplantation by Bone Mineral Densitometry and Biochemical Markers

AIM

This study aimed to evaluate the course of bone and mineral metabolism after liver transplantation (LT) in patients with chronic liver disease.

METHODS

One hundred four patients who had undergone LT and had a minimum of 6 months of follow-up after LT were included in this prospective cohort study. The following parameters were evaluated for each patient: preoperative and postoperative (postoperative day [POD]30, POD90, POD180) osteocalcin, bone-specific alkaline phosphatase (BALP), type 1 collagen, beta-C-terminal end telopeptide (β-CTx), vitamin D, parathyroid hormone (PTH), ALP, calcium, phosphate, sedimentation, and bone mineral densitometer scores (L2, L4, L total, and F total). The parameters were compared in terms of sex, presence of liver tumor (hepatocellular carcinoma [HCC; n = 19] vs non-HCC [n = 85]), and presence of autoimmune liver disease (autoimmune liver disease [ALD; n = 8] vs non-ALD [n = 96]).

RESULTS

The median age of the patients (n = 81 men and n = 23 women) was 52 years (95% CI, 50-56). There was a significant change in the defined time intervals in parameters such as osteocalcin (P < .001), BALP (P < .001), β-CTx (P < .001), vitamin D (P < .001), PTH (P < .001), ALP (P = .001), calcium (P < .001), phosphate (P = .001), L2 (P = .038), L total (P = .026), and F total (P < .001) scores. There was a significant difference in POD90 ALP (P = .033), POD180 calcium (P = .011), POD180 phosphate (P = .011), preoperative sedimentation (P = .032), and POD180 F total (P = .013) scores between both sexes. There was a significant difference in POD180 osteocalcin (P = .023), POD180 β-CTx (P = .017), and preOP calcium (P = .003) among the HCC and non-HCC groups. Furthermore, we found significant differences in preoperative ALP (P = .008), preoperative sedimentation (P = .019), POD90 (P = .037) and POD180 L2 (P = .005) scores, preoperative (P = .049) and POD180 L4 (P = .017), and POD180 L total (P = .010) and F total (P = .022) scores between the patients with and without ALD.

CONCLUSION

This study shows that the bone and mineral metabolism of the LT recipients was negatively affected after LT. In addition, we showed that bone and mineral metabolism was more prominent in patients with HCC, and bone mineral density scores were higher in patients with ALD.