Non-cirrhotic Liver Research Articles

3:18 PM Abstract No. 129 Effect of background liver cirrhosis on performance of a 915-MHz synchronous phased array microwave ablation device: 3D imaging assessment of ablation zone volume and morphology

Evaluate impact of liver cirrhosis on synchronous-phased array microwave heating patterns in vivo, and determine if this technology overcomes known limitations of conventional asynchronous MWA devices used for tumor ablation in cirrhotic livers Retrospective, HIPAA-compliant, IRB-approved. Institution records from Jan 1, 2015 thru Aug 31, 2019 revealed total of 100 liver tumor ablations eligible for inclusion. Cirrhosis confirmed by biopsy or elastography. All treatments performed with CT-guidance and consisted of a single application (burn) using 1 or multiple (up to 3) antennae positioned in parallel or cluster array. Antennae positioned under CT-fluoroscopy. Non-contrast volumetric CT documented antennae alignment, spacing, and position immediately before treatment. Treatment parameters obtained from procedural reports. Contrast-enhanced CT obtained immediately posttreatment to define ablation zone margins. 3D imaging software used to postprocess archived volumetric CT data to calculate ablation zone volume, shape and mean margin variance (MMV = expected ablation defect diameter – observed defect diameter) in 3D space. Ablation defect volume and MMV analyzed for identical treatments based on power/duration, antenna type, number and spacing in normal versus cirrhotic liver using generalized mixed modeling (lognormal distribution), and Fishers Exact test. All analyses conducted using SAS 9.4 with PROC GLIMMIX and FREQ (significance P <0.05) There was significant reduction in ablation defect volume and increase in MMV for single-antenna treatments (asynchronous) performed in cirrhotic versus non-cirrhotic liver at same treatment parameters (P = 0.03). No significant difference in defect volume and MMV between cirrhotic versus non-cirrhotic liver when multi-antennae (synchronous-phased emission) ablation performed (P = 0.03). Controlled for antenna number, MMV was significantly larger in cirrhotic liver (P = 0.04) Synchronous-phased array microwave emission performs equally as well in both cirrhotic and non-cirrhotic liver, thereby conferring a more consistent performance advantage of synchronous over conventional asynchronous microwave emission for ablation of tumors in cirrhotic liver.

Imaging of primary malignant tumors in non-cirrhotic liver

Primary hepatic malignancies in non-cirrhotic liver include a wide spectrum of tumors, which are classified based on their cells of origin. Hepatocellular carcinoma is the most common primary malignant tumor, followed by intrahepatic cholangiocarcinoma. Beside these tumors, other primary malignancies in the non-cirrhotic liver are quite rare. Accurate diagnosis is often difficult with imaging alone and biopsy with further histopathological analysis is often necessary. However, many of these tumors exhibit suggestive or characteristic imaging features due to their different cellular components, allowing radiologists to suggest the correct diagnosis. Thus, the aim of this article is to provide an overview of imaging presentation of primary malignant liver tumors that develop in the non-cirrhotic liver, including potential differential diagnoses. Such knowledge is essential as it may contribute to accurate radiological diagnosis and improved patient outcome.

Natural history of NASH and HCC.

Widespread unhealthy dietary habits associated with a sedentary lifestyle have made NAFLD the most frequent chronic liver disease worldwide, with a global prevalence of ~25%. Although NAFLD is mainly considered to be a benign disease, it can progress to severe liver fibrosis and hepatocellular carcinoma (HCC), with the latter found in non-cirrhotic livers in about 40% of cases. Factors favouring the progression of liver disease in NAFLD are only partially understood. Male sex, older age and Caucasian ethnicity have frequently been identified as factors accelerating the progression of fibrosis in NAFLD, although data are not consistent. Host genetic variants appear to be very important, especially in the gene coding for the patatin-like phospholipase domain-containing 3 (PNPLA3), and they may also play a role in the development of HCC, independent of activity and the extent of liver damage. However, the most important factors affecting disease progression are found in the metabolic syndrome, that is, obesity, type 2 diabetes and arterial hypertension. This mini-review will discuss the contribution of these factors to NAFLD-associated morbidity, emphasizing the importance of preventive measures such as physical activity and weight control in view of the current pandemic of the metabolic syndrome.

Surgical treatment of hepatic tumors-liver resection and transplantation

The most frequent primary hepatic malignancies are hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (intrahepatic cholangiocellular adenocarcinoma [iCCA]). For HCC in cirrhosis, liver transplantation offers the advantage of acomplete hepatectomy radically removing all tumorous tissue along with the surrounding cirrhotic parenchyma, which is otherwise associated with a very high risk of recurrence. For HCC in non-cirrhotic livers and iCCA, liver resection is the treatment of choice. Nowadays, even extended resections can be performed with low mortality in experienced centers. Surgical therapy is more and more embedded into multimodal treatment concepts and decision making should be interdisciplinary as for other gastrointestinal tumors.

Input of serum haptoglobin fucosylation profile in the diagnosis of hepatocellular carcinoma in patients with non-cirrhotic liver disease

Haptoglobin bifucosylated tetra-antennary glycan have been identified in patients with early stage hepatocellular carcinoma, but its specificity according to the presence or not of cirrhosis has never been assessed. The aims of this study were to determine if haptoglobin bifucosylated tetra-antennary glycan (1) could be a marker of HCC in patients without cirrhosis; (2) could increase the performance of standard alpha-fetoprotein (AFP) or recent blood tests for HCC detection, i.e., lectin-reactive alpha-fetoprotein (AFP-L3), des-gamma-carboxy prothrombin (DCP) and Liver-Cancer-Risk-test (LCR1-test). We retrospectively selected patients, 102 with HCC (21 without cirrhosis), matched by stages with 140 controls without HCC (81 without cirrhosis). Haptoglobin fucosylation was assessed by MALDI-TOF. LCR-glycan algorithm was constructed combining components of the LCR-1 test (haptoglobin, gammaglutamyl-transpeptidase, apolipoproteinA1, alpha-2-macroglobulin) with AFP, AFP-L3, DCP and haptoglobin bifucosylated tetra-antennary glycan. In 102 patients without cirrhosis (21 HCC and 81 controls), the intention-to-diagnose analyses showed that haptoglobin bifucosylated tetra-antennary glycan alone had a sensitivity of 71% (15/21;95%CI 50-86), significantly better (P=0.02) than standard AFP (43%;9/21;95%CI 24-63), and a specificity of 96% (78/81;95% 90-99). The sensitivity of LCR-glycan, in patients without cirrhosis, was 86% (18/21; 95%CI 63-95) significantly better (P=0.001) than standard AFP (43%; 9/21; 95%CI 24-63), with an AUROC of 0.943 (95%CI 0.806-0.98) compared to 0.811 (95%CI 0.630-0.908) for AFP (P=0.06). Haptoglobin bifucosylated tetra-antennary glycan is associated with the presence of HCC in patients with chronic liver disease including those without cirrhosis. Its combination with existing HCC biomarkers could improve the performance of standard AFP for HCC detection.

Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial.

Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula. This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed. A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P=1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P=0·731), mortality (2·5 versus 4·7 per cent; P=0·367) and reoperations (4·4 versus 10·1 per cent; P=1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P=0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface. This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).

Liver surgery is safe in compensated liver cirrhosis

Background: Liver resection is a standard treatment for primary and secondary livertumours. However, primary liver tumours often arise from cirrhotic livers. The aim of this study was to compare outcome for liver resection in cirrhotic and non-cirrhotic liver. Material and Methods: 264 patients who underwent liver resection between 2008 and 2017 at the university hospital Mainz were analysed. They were categorized into three groups: group 1: HCC in cirrhosis (n=84, 32%), group 2: HCC in non-cirrhotic liver (n=96, 36%) and group 3: CRC-metastases (n=84, 32%) matched to group. Comorbidity following the Charlson Comorbidity Index, pre- and postoperative liver function according to Meld- and Child score as well as encephalopathy and ascites, postoperative complications according the Dindo-Clavien classification and the extent of liver resection were registered. ROC analysis was performed in order to determine cut-off levels for morbidity and mortality. P-values <0.05 were='' considered='' significant='' br=''> Results: Morbidity was not different between HCC in cirrhosis and non-cirrhotic livers, but HCC in non-cirrhotic livers had significantly more major resections (p<0.05). Patients with CRC-Metastases had significantly fewer preoperative liver decompensation, and had fewer postoperative complications grade IIIa-IVb compared to the patients with HCC in cirrhosis (29.8% vs 16.7%, p=0.045). Mortality was 1.2% in group 1, 2.1% and 1.2% in groups 2 and 3, respectively (ns). There was no difference in the postoperative mortality between the groups. ROC-analyses revealed that the preoperative Meld-Score was a poor predictor for postoperative complications as well as for postoperative liver function. Comorbidity had no statistically relevant effect on the outcome, too. Conclusion: Surgery in liver cirrhosis can be safely performed with very low mortality. As neither preoperative Meld-Score nor comorbidity is a reliable predictor for the postoperative outcome each patient should be evaluated individually.

Mortality after Transplantation for Hepatocellular Carcinoma: A Study from the European Liver Transplant Registry

Background and Aims: Prognosis after liver transplantation differs between hepatocellular carcinoma (HCC) arising in cirrhotic and non-cirrhotic livers and aetiology is poorly understood. The aim was to investigate differences in mortality after liver transplantation between these patients. Methods: We included patients from the European Liver Transplant Registry transplanted due to HCC from 1990 to November 2016 and compared cirrhotic and non-cirrhotic patients using propensity score (PS) calibration of Cox regression estimates to adjust for unmeasured confounding. Results: We included 22,787 patients, of whom 96.5% had cirrhosis. In the unadjusted analysis, non-cirrhotic patients had an increased risk of overall mortality with a hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.23–1.52). However, the HR approached unity with increasing adjustment and was 1.11 (95% CI 0.99–1.25) when adjusted for unmeasured confounding. Unadjusted, non-cirrhotic patients had an increased risk of HCC-specific mortality (HR 2.62, 95% CI 2.21–3.12). After adjustment for unmeasured confounding, the risk remained significantly increased (HR 1.62, 95% CI 1.31–2.00). Conclusions: Using PS calibration, we showed that HCC in non-cirrhotic liver has similar overall mortality, but higher HCC-specific mortality. This may be a result of a more aggressive cancer form in the non-cirrhotic liver as higher mortality could not be explained by tumour characteristics or other prognostic variables.

ALPPS and minialpps. Alternatives between liver hypertrophy techniques. Presentation of two cases in liver disease of non-colorectal origin

Presenter: Fabio Vergara MD | IPS Universidad de Antioquia, Clinica Leon XIII Background: Liver resections are the treatment of choice for most liver tumors. Thanks to liver regeneration, various procedures have appeared to stimulate liver hypertrophy in cases where it is required. Among them is the ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy), which consists of performing a hepatectomy in two stages, achieving faster hypertrophy and in less time. This surgical technique can have high morbidity and mortality rates, so it is very important to properly select patients. In recent years, groups from Chile and Argentina have developed a variant in this technique which they have called Mini-ALPPS, where the hepatic transection is minor, thus reducing the morbidity that this part of the surgery can bring. Methods: We present two cases of ALPPS and Mini-AlPPS in liver disease of non colorectal origin. The first case of a two-stage hepatectomy using ALPPS is a 65-year-old male patient, with MRI of the abdomen shows a giant liver in the right lobe and part of segment IV compatible with probable hepatocarcinoma over non-cirrhotic liver. Hepatic volumetry show insufficient hepatic remnant, it was decided to perform an ALPPS with the aim of obtaining a faster hepatic hypertrophy. The first time was performed by laparoscopic technique, achieving right portal ligation and hepatic transection. At 10 days, a new abdominal tomography was performed to assess hypertrophy. Then proceed to the second time of the ALPPS, with an open approach. Hepatic transection is completed with right hepatic artery ligation, right bile duct control and right hepatic vein section. In the second case we used de Mini-ALLPS strategy. A 52-year-old woman with a history of resected retroperitoneal sarcoma. In the follow-up hepatic recurrence of sarcoma. MRI confirms presence of hepatic bilobar disease in the right lobe and segment IV with a single lesion in the left lateral section. It was decided to perform MiniALPPS with resection of the metastasis of the left lateral section, right portal ligation and hepatic section of 3cms deep in the firs stage. At 10 postoperative days a CT scan of the abdomen shows compensatory hypertrophy of the left lateral section. In the second stage an extended right hepatectomy was performed. Results: In the two cases the procedure was uncomplicated, did not require blood transfusion or vasopressor support, extubation and transfer to the ICU was achieved for surveillance. The ALPPS case had no signs of liver failure, he was discharged after 8 days. The pathology shows a hepatocarcinoma on non-cirrhotic liver. The MiniALPPS case has present type B postoperative liver failure, it required vasopressor support and blood transfusion. The pathology confirmed sarcoma metastases Conclusion: ALPPS and MiniALPPS are an alternative in the treatment of liver tumors where the liver remnant is insufficient. They can use when the cause of its tumor biology and we need a hypertrophy is less time or when the other ways of generating hypertrophy are failed. However, it is a procedure that can have high morbidity and mortality, so it is important to select patients in a multidisciplinary team.

Differential expression of angiogenesis-related miRNAs and VEGFA in cirrhosis and hepatocellular carcinoma.

IntroductionLiver cirrhosis (LC) is a heterogeneous liver disease, the last stage of liver fibrosis, and the major risk factor for hepatocellular carcinoma (HCC). Our study aimed to evaluate the expression of microRNAs and the endothelial vascular growth factor (VEGFA) gene in LC and HCC.Material and methodsThe sample group consisted of 46 tissue samples: 21 of LC, 15 of HCC, and 10 of non-tumoural and non-cirrhotic liver tissue (control group). MiRNAs were chosen based on a mirDIP prediction database as regulators of the VEGFA gene. Gene expression of VEGF and miRNAs was quantified by real-time quantitative polymerase chain reaction. VEGFA protein expression was evaluated by ELISA.ResultsVEGFA gene expression was significantly overexpressed in LC compared to the control group (p < 0.0001). Hsa-miR-206 (p = 0.0313) and hsa-miR-637 (p = 0.0156) were down-expressed in LC. In HCC, hsa-miR-15b (p = 0.0010), hsa-miR-125b (p = 0.0010), hsa-miR-423-3p (p = 0.0010), hsa-miR-424 (p = 0.0313), hsa-miR-494 (p < 0.0001), hsa-miR-497 (p < 0.0001), hsa-miR-612 (p = 0.0078), hsa-miR-637 (p < 0.0001), and hsa-miR-1255b (p = 0.0156) presented down-expression.ConclusionsOverexpression of VEGFA in LC suggests impairment of angiogenesis in this tissue. The differential expression of microRNAs in LC and HCC observed in our study can lead to the evaluation of possible biomarkers for these diseases.

Hepatocellular carcinoma in the non-cirrhotic liver: a two-center experience with 19 cases

Background: Hepatocellular carcinoma is the most common type of primary liver cancer and is the third cause of cancer related deaths; 80% of the HCC are associated with cirrhotic livers or chronic liver diseases, which constitute the main risk factor. Chronic inflammation, necrosis and regeneration due to these conditions produce genetic mutation and development of tumor cells. Yet, 10% develop in non-cirrhotic healthy livers without precipitating factors. Material and methods: We conducted a retrospective analysis of the characteristics and survival of patients with diagnosis of hepatocellular carcinoma in non-cirrhotic liver and absence of a history of liver cirrhosis or chronic liver disease undergoing surgery in two hepato-pancreato-biliary units between January 2007 and January 2016. Results: Mean age was 65 years and 13 patients were men. Abdominal pain was the most common clinical presentation. Liver panel was normal in 60% of the cases and alpha-fetoprotein was elevated in only 16%. The diagnosis was made by imaging tests in 61% of the cases. Mean tumor size was 110.6 cm. All the patients underwent surgery. Complications were observed in 36.8% of the patients and survival at 5 years was 62.3%. Conclusion: hepatocellular carcinoma is usually diagnosed as a large lesion in imaging tests ordered due to abdominal pain. Surgery provides curative treatment, and large resections can be safely performed, with low perioperative morbidity and mortality and low incidence of postoperative liver failure,since the liver remnant is healthy and liver function is maintained.

Role of CD8 Cytotoxic T Lymphocytes in Hepatocellular Carcinoma: An Immunohistochemical Study

AbstractBackground: Hepatocellular Carcinoma (HCC) is the most common primary malignancy of the liver in adults accounting for 85%-90% of liver tumors. It represents the sixth most common malignancy and the fourth leading cause of cancer-related death worldwide. There is an important role of CD8+ tumor infiltrating lymphocytes in host immune defense against tumour progression. Immunotherapy, with modern pharmacologic developments, is a new direction in cancer therapy and therefore immunobiology of hepatocar-cinogenesis is under investigation.Aim of Study: Study expression of CD8 in Hepatocellular carcinoma and its correlation with clinicopathological param-eters and explore its effect on HCC prognosis.Material and Methods: This study included 112 hepato-cellular carcinoma cases obtained from the archival material of Pathology Department, National Liver Institute, Menoufia University, between 2010 and 2017. All cases were stained for CD8 antibody. Survival data were available for all HCC cases.Results: CD8 was expressed in 110 HCC cases (98.2%). There was a statistical significant association between high CD8 percentage and non-cirrhotic adjacent liver (p=0.035). On the other hand, there was a significant association between high CD8 percentage and large tumor size (<5cm) (p=0.015). There was no statistically significant association between CD8 expression and overall survival or recurrence.Conclusion: We concluded that high CD8 might serve as bad prognostic parameter in HCC as it is associated with non-cirrhotic liver and large tumor size but it doesn't affect HCC overall survival or recurrence.

The visualisation of focal liver lesions on ultrasound: A review of 300 liver ultrasounds with CT or MRI correlation

AbstractIntroductionConventional ultrasound (US) is the most common imaging investigation of the liver. The ability of US to visualise focal liver lesions (FLLs) can be limited by technical factors, patient characteristics, and operator experience. The aim of this study was to determine the percentage and types of FLLs that were visualised on conventional US when compared with CT or MRI.MethodologyThree hundred patients who received a US followed by CT or MRI within 10 days were retrospectively reviewed. The final outcome of all liver lesions was determined by the best available evidence.ResultsIn noncirrhotic livers, 168 FLLs were visualised ranging from 2 to 62 mm in size. The most common lesions were cysts (n = 107, 64%), indeterminate FLLs (n = 20, 12%), haemangiomas (n = 11, 7%), other benign FLLs (n = 10, 6%), and metastases (n = 9, 5%). US visualised 39 (23%) FLLs and failed to visualise 129 (77%). The visualisation of FLL increased with increasing lesion size. FLLs less than 10 mm were seldom visualised, whereas FLLs greater than 15 mm were visualised two‐thirds of the time. In cirrhotic livers, US failed to visualise malignant lesions in two patients. Disseminated metastatic liver disease was visualised on US in 94% of cases.ConclusionConventional US continues to play a major role in the screening for focal liver disease. US practitioners and clinicians should be aware that the ability of US to visualise FLLs is size dependent and may be limited in some patients.

ESGCT 27th Annual Congress In collaboration with SETGyc Barcelona, Spain October 22–25, 2019 Abstracts

Xenotransplantation of transgenic porcine pancreatic islets offers a promising alternative source to circumvent current limitations posed by the scarcity of allogeneic donors. We have investigated the feasibility to generate tissue engineered SLA silenced islet cell clusters (ICC) to decrease xenogeneic immune responses Pancreatic islets single cell suspensions were generated by enzymatic digestion of porcine ICCs. Single cells were silenced for SLA expression by lentiviral vectors encoding for Nanoluciferase as reporter gene and for short hairpin RNAs targeting beta2-microglobulin or class II transactivator, respectively. SLA transcripts were evaluated by real-time PCR and protein levels by flow cytometry and fluorescence microscopy analyses. The effect of SLA silencing was evaluated in human T and NK cell cytotoxicity assays. SLA-silenced pancreatic beta-cells were then reassembled into ICCs in stirred bioreactors. SLA class I silencing reached a level of up to 84% and class II by up to 50% on pancreatic islet cell. Silencing SLA expression did not affect cell viability and the insulin-producing beta-cell phenotype. Xenogeneic T-cell immune responses (p < 0.05) as well as antibody-mediated cellular-dependent immune responses (p < 0.01) were significantly decreased. Silencing SLA class I expression did not increase susceptibility to NK-cell cytotoxicity. In stirred bioreactors, tissue engineered islets showing the typical 3D-structure and morphology of ICC were assembled from SLA-silenced pancreatic cell suspensions. These data shows the feasibility to generate low immunogenic porcine ICC from transgenic pigs after single cell engineering and post-transduction islet reassembling that might serve as a robust alternative to allogeneic pancreatic islet cell transplantation.

A RARE CASE OF HYPERAMMONEMIC ENCEPHALOPATHY FOLLOWING BARIATRIC SURGERY: EXACERBATED BY POSTOPERATIVE MALNUTRITION

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Bariatric surgery is now a popular weight reduction method for obesity-related morbidity and mortality. Recently, cases with hyperammonemia after gastric bypass surgery have been reported. CASE PRESENTATION: A 66-year-old woman with a history of non-alcoholic fatty liver disease, remote Roux-en-Y gastric bypass surgery, and multiple abdominal surgeries presented with septic shock from abdominal wound infection. Her hospital course was complicated by recurrent episodes of sepsis and inadequate oral intake leading to malnutrition which resulted in difficulty in closing her abdominal wounds. The patient was transferred to the medical intensive care unit for septic shock and altered mental status on hospital day 60th. Overall her clinical condition improved within several days after broad antibiotics and vasopressors were started for septic shock. Despite her clinical improvement, she remained obtunded and minimally responsive to stimuli. Ammonia level was 92 umol/L, lactulose and rifaximin were started empirically for hyperammonemic encephalopathy. CT head and MRI brain were not revealing. An electroencephalogram showed triphasic waves consistent with metabolic encephalopathy. In spite of 3-4 loose stools with lactulose and rifaximin, her mental status remained unchanged. Repeat ammonia level was elevated to 145 umol/L. Post gastric bypass hyperammonemic syndrome was suspected, therefore L carnitine, multivitamin, and zinc supplement were started. The patient’s mental status started improving from the next day. Ammonia level decreased to 53 umol/L subsequently. The patient had wound closure on hospital day 66th, and she was subsequently transferred to the general floor. DISCUSSION: Since extensive work-up did not reveal a cause of altered mental status, our hypothesis was that post gastric bypass micronutrient deficiency provoked hyperammonemia. Since she had multiple polymicrobial infection, urea forming bacterial infection could have been other contributing factor. This hypothesis was supported by improvement of her hyperammonemic encephalopathy after treatment of sepsis and supplement of micronutrient. Hyperammonemia following bariatric surgery in the context of non-cirrhotic liver condition is challenging. Our case had previously reported common features: preceding gastric bypass surgery, hyperammonemic encephalopathy, absence of cirrhosis, hypoalbuminemia, and nutritional complications. Early suspicion of this pathology and follow up of ammonia was successful. CONCLUSIONS: Postoperative malnutrition exaggerates post gastric bypass nutritional complication and could lead to hyperammonemic encephalopathy following bariatric surgery. Clinicians should have a high index of suspicion for this rare complication and evaluate ammonia level. Reference #1: Fenves AZ, Shchelochkov OA, Mehta A. Obesity. 2015 Apr; 23(4):746-9. Hyperammonemic syndrome after Roux-en-Y gastric bypass. DISCLOSURES: No relevant relationships by Toshiki Kuno, source=Web Response No relevant relationships by Young Im Lee, source=Web Response No relevant relationships by Reiichiro Obata, source=Web Response

Surgical treatment results of hepatocellular carcinoma in non-cirrhotic liver in southern Chile: case series with follow-up.

Hepatocellular carcinoma is the most frequent primary tumour of the liver. Although often associated with chronic liver disease, it can also occur in non-cirrhotic livers. The aim of this study was to describe post-operative morbidity (POM), and survival of patients with hepatocellular carcinoma in non-cirrhotic liver treated surgically, and to identify variables associated with prognosis. Case series of patients who underwent surgery for hepatocellular carcinoma in non-cirrhotic liver at Clínica RedSalud Mayor de Temuco, Chile (2001-2017), were studied. The minimum follow-up time considered was 12 months. Principal outcomes were development of POM and survival. Other variables of interest were age, sex, tumour diameter, surgical time, hospital stay, follow-up time, need for surgical re-intervention, mortality, vascular and lymph node invasion and staging. Descriptive and analytic statistics were calculated. A total of 32 patients were studied. They were characterized by a mean age of 67.3 ± 7.2 years, 62.5% of whom were men. Averages of tumour diameter, surgical time and hospitalization were 12.0 ± 2.6 cm, 114.4 ± 32.3 min and 7.2 ± 2.9 days, respectively. POM was 31.3%. There was no mortality and there were no re-interventions. The overall actuarial survival at 1, 2 and 3 years was 96.8%, 73.4% and 17.3%, respectively. Lower survival was verified in patients with vascular invasion, lymph node infiltration and stages III and IVa. Despite the tumour diameter and extent of the resections, POM in patients with hepatocellular carcinoma in non-cirrhotic liver is moderate. However, its prognosis is poor. Vascular invasion, lymph node invasion and advances stages were associated with worse survival.

Non-Cirrhotic Liver is Associated with Poor Prognosis of Hepatocellular Carcinoma: A Literature Review.

Primary hepatocellular carcinoma (HCC) is the fifth most frequently reported malignancy, and it is also the second most common cause of cancer-related deaths worldwide. Although most HCC cases have been reported to develop from cirrhosis, accumulating data suggest that HCC is also closely related to non-cirrhotic chronic liver disease. Traditionally, HCC was thought to develop mostly from cirrhosis; however, an increasing number of reports have found that HCC can develop directly from inflammation without cirrhosis. The incidence of HCC in non-cirrhotic liver (HCC-NCL) is high, especially in developed countries. Studies have found that the most common cause of HCC-NCL is neglected fatty liver disease. This type of HCC has unique clinical characteristics and is closely related to metabolic disorders. Unfortunately, the prevention of HCC-NCL has not received enough attention worldwide, and there is also a lack of specific screening methods and clinical guidelines. This article mainly reviews the etiology, incidence, clinical characteristics, and screening markers of HCC-NCL to improve the understanding and prevention of this disease.

Development and validation of a risk score to predict the overall survival following surgical resection of hepatocellular carcinoma in non-cirrhotic liver

BackgroundThe aim of this study was to develop and validate a risk score to predict overall survival (OS) in patients undergoing surgical resection for hepatocellular carcinoma in non-cirrhotic liver (NC-HCC). MethodsPatients who underwent resection for NC-HCC between 2004 and 2013 were identified from the SEER database. A derivation set of 75% of this cohort was used to develop a risk score. This was then internally validated on the remaining patients, and externally validated using a cohort of patients from The HPB Unit, Birmingham, UK. ResultsA total of 3897 patients were included from the SEER database, with a median post-diagnosis survival of 59 months. In the derivation set, multivariable analyses identified male sex, increasing tumour size, the presence of multiple tumours, bilobar tumours and major vascular invasion as adverse prognostic factors. A risk score generated from these factors was significantly predictive of OS, and was used to classify patients into low, medium and high-risk groups. These groups had a five-year OS of 69%, 51% and 19% in the internal, and 73%, 50% and 45% in the external validation sets. ConclusionThe proposed risk score is useful in the selection, pre-operative consenting and counselling of patients for surgery and to allow patients to make an informed decision regarding treatment.

Tips and Tricks in Contrast-Enhanced Ultrasound (CEUS) for the Characterization and Detection of Liver Malignancies.

Contrast-enhanced ultrasound (CEUS) has a high diagnostic accuracy in the assessment of focal liver lesions. Clinical context (presence of liver cirrhosis, history of other malignancy versus incidental finding) is crucial for the correct interpretation of CEUS findings. CEUS has to be preceded by structured anamnesis and clinical examination as well as accurate B-mode sonography. Metastases are the most common malignant liver lesions in a non-cirrhotic liver. According to their contrast enhancement in the arterial phase, metastases are categorized as hyper- and hypo-vascular metastases. A common feature of all metastatic lesions is washout of the contrast agent in the portal venous or late phase. In the context of liver cirrhosis, > 95 % of focal liver lesions are hepatocellular carcinomas (HCCs). HCCs typically show arterial phase hyperenhancement, followed by mild and gradual contrast washout occurring very late in the late phase. For intrahepatic cholangiocellular carcinoma (ICC), the pattern of contrast enhancement in the arterial phase can vary. However, all ICCs typically show early and pronounced washout. Other liver malignancies like lymphoma, angiosarcoma, epithelioid hemangioendothelioma and others are very rare. Except for the contrast washout seen in all liver malignancies, they do not display pathognomonic enhancement patterns upon CEUS. Thus, biopsy is indispensable for definite diagnosis of the tumor entity. Furthermore, CEUS is used for the detection of metastases and therapeutic monitoring after local ablative procedures. The examination procedure differs slightly depending on the specific indication (characterization, detection).

Expanding the Liver Imaging Reporting and Data System (LI-RADS) v2018 diagnostic population: performance and reliability of LI-RADS for distinguishing hepatocellular carcinoma (HCC) from non-HCC primary liver carcinoma in patients who do not meet strict LI-RADS high-risk criteria

BackgroundHepatocellular carcinoma (HCC) can be diagnosed using imaging criteria in patients at high-risk for HCC, according to Liver Imaging Reporting and Data System (LI-RADS) guidelines. The aim of this study was to determine the diagnostic performance and inter-rater reliability (IRR) of LI-RADS v2018 for differentiating HCC from non-HCC primary liver carcinoma (PLC), in patients who are at increased risk for HCC but not included in the LI-RADS ‘high-risk’ population. MethodsThis retrospective HIPAA-compliant study included a 10-year experience of pathologically-proven PLC at two liver transplant centers, and included patients with non-cirrhotic hepatitis C infection, non-cirrhotic non-alcoholic fatty liver disease, and fibrosis. Two readers evaluated each lesion and assigned an overall LI-RADS diagnostic category, additionally scoring all major, LR-M, and ancillary features. ResultsThe final study cohort consisted of 27 HCCs and 104 non-HCC PLC in 131 patients. The specificity of a ‘definite HCC’ designation was 97% for reader 1 and 100% for reader 2. The IRR was fair for overall LI-RADS category and substantial for most major features. ConclusionIn a population at increased risk for HCC but not currently included in the LI-RADS ‘high-risk’ population, LI-RADS v2018 demonstrated very high specificity for distinguishing pathologically-proven HCC from non-HCC PLC.