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Background: In the treatment of liver metastasis of gastrointestinal stromal tumour (GIST), the role of hepatectomy is controversial. This study tried to identify such role by investigating the immediate and long-term surgical outcomes., Methods: Data of patients who underwent hepatectomy to treat their metastatic disease were reviewed. Patients whose liver tumours were confirmed to be metastatic GISTs were included for analysis. Clinicopathological characteristics of the primary disease, time of metastasis development and modes of treatment were recorded. Immediate outcome and long-term survival after hepatectomy were analysed., Results: Ten patients were confirmed to have isolated liver metastasis of GIST. Their median age was 61 (42-74) years. All of them had normal liver function and no cirrhosis. Seven patients received major hepatectomy and three patients received minor hepatectomy. The median operation time was 319.5 (122-735) min. The median tumor size was 5.5 (1.5-15) cm. No hospital death occurred. The 1-, 3- and 5-year overall survival rates were 100, 75 and 50%, respectively and the corresponding disease-free survival rates were 70, 42 and 14%, respectively., Conclusion: Treating isolated liver metastasis of GIST with hepatectomy is effective and safe. Favourable long-term overall survival and disease-free survival can be achieved., (© 2013 Royal Australasian College of Surgeons.)

Background & Aims: High-intensity focused ultrasound (HIFU) ablation is a non-invasive treatment for unresectable hepatocellular carcinomas (HCCs), but long-term survival analysis is lacking. This study was to analyse its outcome compared to that of transarterial chemoembolization (TACE)., Methods: From October 2003 to September 2010, 113 patients received HIFU ablation as a treatment of HCCs at our hospital. Twenty-six patients had HCCs sized 3-8 cm. Fifty-two patients with matched tumour characteristics having TACE as primary treatment were selected for comparison. Short-term outcome and long-term survival were analysed., Results: In the HIFU group (n = 26), 46 tumours were ablated. The median age of the patients was 69 (49-84) years. The median tumour size was 4.2 (3-8) cm. In the TACE group (n = 52), the median age of the patients was 67 (44-84) years. The median tumour size was 4.8 (3-8) cm. There was no hospital mortality in any of the groups. In the HIFU group, the rates of complete tumour response, partial tumour response, stable disease and progressive disease were 50%, 7.7%, 25.6% and 7.7% respectively, according to the modified Response Evaluation Criteria in Solid Tumours. The TACE group had the corresponding rates at 0%, 21.2%, 63.5% and 15.4% respectively (P < 0.0001). The 1-year, 3-year and 5-year survival rates were 84.6%, 49.2% and 32.3% respectively, in the HIFU group and 69.2%, 29.8% and 2.3% respectively, in the TACE group (P = 0.001)., Conclusion: HIFU ablation is a safe and effective method for unresectable HCCs. A survival benefit is observed over sole TACE., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background & Aims: We aimed to develop a prognostic classification scheme with treatment guidance for Asian patients with hepatocellular carcinoma (HCC)., Methods: We collected data from 3856 patients with HCC predominantly related to hepatitis B treated at Queen Mary Hospital in Hong Kong from January 1995 through December 2008. Data on patient performance status, Child-Pugh grade, tumor status (size, number of nodules, and presence of intrahepatic vascular invasion), and presence of extrahepatic vascular invasion or metastasis were included, and randomly separated into training and test sets for analysis. Cox regression and classification and regression tree analyses were used to account for the relative effects of factors in predicting overall survival times and to classify disparate treatment decision rules, respectively; the staging system and treatment recommendation then were constructed by integration of clinical judgments. The Hong Kong Liver Cancer (HKLC) classification was compared with the Barcelona Clinic Liver Cancer (BCLC) classification in terms of discriminatory ability and effectiveness of treatment recommendation., Results: The HKLC system had significantly better ability than the BCLC system to distinguish between patients with specific overall survival times (area under the receiver operating characteristic curve values, approximately 0.84 vs 0.80; concordance index, 0.74 vs 0.70). More importantly, HKLC identified subsets of BCLC intermediate- and advanced-stage patients for more aggressive treatments than what were recommended by the BCLC system, which improved survival outcomes. Of BCLC-B patients classified as HKLC-II in our system, the survival benefit of radical therapies, compared with transarterial chemoembolization, was substantial (5-year survival probability, 52.1% vs 18.7%; P < .0001). In BCLC-C patients classified as HKLC-II, the survival benefit of radical therapies compared with systemic therapy was even more pronounced (5-year survival probability, 48.6% vs 0.0%; P < .0001)., Conclusions: We collected data from patients with HCC in Hong Kong to create a system to identify patients who are suitable for more aggressive treatment than the currently used BCLC system. The HKLC system should be validated in non-Asian patient populations and in patients with different etiologies of HCC., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: The indocyanine green (ICG) retention test is the most popular liver function test for selecting patients for major hepatectomy. Traditionally, it is done using spectrophotometry with serial blood sampling. The newly-developed pulse spectrophotometry is a faster alternative, but its accuracy on Child-Pugh A cirrhotic patients undergoing hepatectomy for hepatocellular carcinoma has not been well documented. This study aimed to assess the accuracy of the LiMON(®), one of the pulse spectrophotometry systems, in measuring preoperative ICG retention in these patients and to devise an easy formula for conversion of the results so that they can be compared with classical literature records where ICG retention was measured by the traditional method., Methods: We measured the liver function of 70 Child-Pugh A cirrhotic patients before hepatectomy for hepatocellular carcinoma from September 2008 to January 2009. ICG retention at 15 minutes measured by traditional spectrophotometry (ICGR15) was compared with ICG retention at 15 minutes measured by the LiMON (ICGR15(L))., Results: The median ICGR15 was 14.7% (5.6%-32%) and the median ICGR15(L) was 10.4% (1.2%-28%). The mean difference between them was -4.3606. There was a strong correlation between ICGR15 and ICGR15(L) (correlation coefficient, 0.844; 95% confidence interval, 0.762-0.899). The following formula was devised: ICGR15=1.16XICGR15(L)+2.73., Conclusions: The LiMON provides a fast and repeatable way to measure ICG retention at 15 minutes, but with constant underestimation of the real value. Therefore, when comparing results obtained by traditional spectrophotometry and the LiMON, adjustment of results from the latter is necessary, and this can be done with a simple mathematical calculation using the above formula.

Microvascular invasion is a poor prognostic indicator of the recurrence of hepatocellular carcinoma (HCC) after surgical treatment. Positron emission tomography (PET) with [(18) F]fludeoxyglucose ([(18) F]FDG) as a tracer has been employed to predict the prognosis before surgery for various kinds of tumors, but it has not been found to be sensitive enough for HCC. Thus, [(11) C]acetate has been adopted as an additional tracer. This study was designed to evaluate the ability of dual-tracer PET ([(18) F]FDG and [(11) C]acetate) to predict microvascular invasion before liver resection or transplantation. Fifty-eight HCC patients who were preoperatively examined with whole-body dual-tracer PET were studied. Twenty-five patients were [(18) F]FDG-positive, and 56 were [(11) C]acetate-positive. The sensitivity of [(18) F]FDG in detecting primary HCC was 43%, and the sensitivity of [(11) C]acetate was 93%. Twenty-nine patients had HCC with microvascular invasion according to the final pathological examination. The sensitivity, specificity, positive predictive value, and negative predictive value of [(18) F]FDG PET in predicting microvascular invasion were 55.2%, 69%, 64%, and 60.6%, respectively; the corresponding rates for [(11) C]acetate PET were 93.1%, 0%, 48.2%, and 0%. The factors associated with HCC recurrence, which included multifocal involvement, a large tumor size, microsatellite lesions, poor HCC differentiation, and an advanced stage of disease, were analyzed and compared with positive PET results. A tumor size greater than 5 cm was significantly associated with positive [(18) F]FDG PET results; [(11) C]acetate was not associated with poor prognostic indicators. Preoperative [(18) F]FDG PET may predict microvascular invasion. The addition of [(11) C]acetate improves the overall sensitivity of PET, but it has no incremental value in predicting microvascular invasion., (Copyright © 2011 American Association for the Study of Liver Diseases.)

Tumour recurrence and metastasis are pressing issues of hepatocellular carcinoma (HCC) patients who receive surgical treatments. Matrix metalloproteinase-12 (MMP-12), previously identified from our animal model, is involved in tumour invasiveness of rat hepatoma. We aimed to investigate the significance and prognostic value of MMP-12 expression in human HCC. MMP-12 mRNA level of 139 pairs of tumour and non-tumour liver tissues of HCC patients after hepatectomy were investigated by quantitative real-time RT-PCR. MMP-12 mRNA was significantly elevated in tumour liver tissues of HCC patients compared to non-tumour and normal liver tissues. By comparing paired tumour and non-tumour liver tissues, MMP-12 mRNA was overexpressed in 58% of tumour tissue of HCC patients. Overexpression of MMP-12 mRNA was significantly correlated with presence of venous infiltration (p=0.004), high serum AFP level (p=0.012), early tumour recurrence (p=0.018) and poor overall survival (p=0.02) of HCC patients. Moreover, MMP-12 mRNA was an independent factor in predicting the 1- and 3-year overall survival of HCC patients after hepatectomy. Our data demonstrated that MMP-12 mRNA may be a valuable prognostic marker for both overall survival and tumour recurrence of HCC patients after liver resection., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To investigate the trend of the posthepatectomy survival outcomes of hepatocellular carcinoma (HCC) patients by analysis of a prospective cohort of 1198 patients over a 20-year period., Background: The hospital mortality rate of hepatectomy for HCC has improved but the long-term survival rate remains unsatisfactory. We reported an improvement of survival results 10 years ago. It was not known whether there has been further improvement of results in recent years., Methods: The patients were categorized into two 10-year periods: period 1, before 1999 (group 1, n = 390) and period 2, after 1999 (group 2, n = 808). Patients in group 2 were managed according to a modified protocol and technique established in previous years., Results: The patients in group 2 were older and had a higher incidence of comorbid illness and cirrhosis. They had a lower hospital mortality rate (3.1% vs 6.2%, P = 0.012) and longer 5-year overall survival (54.8% vs 42.1%, P < 0.001) and disease-free survival rates (34.8% vs 24%, P = 0.0024). An improvement in the overall survival rate was observed in patients with cirrhosis, those undergoing major hepatectomy, and those with tumors of tumor-node-metastasis stages II, IIIA, and IVA. A significant increase in the survival rates was also seen in patients whose tumors were considered transplantable by the Milan criteria (72.5% vs 62.7%, P = 0.0237). Multivariate analysis showed a significantly more favorable patient survival for hepatectomy in period 2., Conclusions: A continuous improvement of survival outcomes after hepatectomy for HCC was achieved in the past 20 years even in patients with advanced diseases. Hepatectomy remains the treatment of choice for resectable HCC in a predominantly hepatitis B virus-based Asian population.

The middle hepatic vein may be included in right liver living donor liver transplantation (LDLT) to optimize hepatic venous outflow. We studied the graft's ability to relieve portal hypertension and accommodate portal hyperperfusion with portal manometry and ultrasonic flowmetry. Surgical outcomes with respect to portal hemodynamometry were also investigated. The ages of the recipients and donors for 46 consecutive LDLT procedures were 50 (range, 16-66 years) and 31 years (range, 18-54 years), respectively. The graft to standard liver volume ratio was 47.4% (range, 32.4%-69.0%). The hospital mortality rate was 4.4% as 2 recipients died from a subarachnoid hemorrhage and sepsis. The portal pressure dropped by 8 mm Hg (range, -7 to 19 mm Hg) from 23 (range, 8-37 mm Hg) to 14 mm Hg (range, 10-26 mm Hg) after graft implantation. The portal inflow positively correlated with the portal pressure before native liver hepatectomy (R(2) = 0.305, P = 0.001) and not with the graft size. The portal inflow increased from 81 mL/minute/100 g (range, 35-210 mL/minute/100 g) before donor right hepatectomy to 318 mL/minute/100 g (range, 102-754 mL/minute/100 g) after graft implantation. The graft portal inflow had a positive linear correlation with the recipient portal pressure before native liver total hepatectomy (R(2) = 0.261, P = 0.001) but not after graft implantation, and it had a negative correlation with the graft to standard liver volume ratio (R(2) = 0.247, P = 0.001). Only 1 of the graft biopsies showed moderate sinusoidal congestion. Twelve recipients had Clavien grade 2+ complications that were not related to the portal inflow and pressure or graft size. Right liver LDLT including the middle hepatic vein effectively lowered the recipient portal pressure by allowing unimpeded venous outflow., (Copyright © 2011 American Association for the Study of Liver Diseases.)

Orthotopic liver transplantation (OLT) is the best treatment option for selected patients with hepatocellular carcinoma (HCC) with the background of cirrhosis since this treatment modality can cure both diseases at once. Over the years, the applicability of OLT for HCC has evolved. In Asia, including Hong Kong, a shortage of deceased donor liver grafts is a universal problem having to be faced in all transplant centers. Living-donor liver transplant (LDLT) has therefore been developed to counteract organ shortage and the high prevalence of HCC. The application of LDLT for HCC is a complex process involving donor voluntarism, selection criteria for the recipient and justification with respect to long-term survival in comparison to the result of deceased donor liver transplant. This article reviews the authors' experience with OLT for HCC patients in Hong Kong, with emphasis on the applicability and outcome of LDLT for HCC. Donor voluntarism has a significant impact on the application of LDLT. "Fast-track" LDLT in the setting of recurrence following curative treatment carries a high risk of recurrence even though the tumor stage fulfills the standard criteria. Although the survival outcome may be worse following LDLT than DDLT for HCC, LDLT is still the main treatment option for patients with transplantable HCC in Hong Kong, and a reasonable survival outcome can be achieved in selected patients with extended indications. It is particularly true that LDLT provides the only hope for patients with advanced HCC under the constricting problem of organ shortage.

Liver transplantation is a life-saving treatment modality, but is hindered by the scarcity of deceased-donor liver grafts. To acquire more liver grafts and thus save more lives, various techniques have been devised and policies adopted, including living-donor, split-graft and sequential liver transplantation; extended donor criteria; and donation after cardiac death. However, with these techniques and policies come a range of entailed medical concerns and concomitant ethical dilemmas, mainly bearing on the welfare of donors and potential donors. In this article, we provide an overview of how the transplant community works towards the end of extending the liver donor pool, with the aim of ensuring that more liver transplant candidates receive their transplant as early as possible. The current strategies in Hong Kong in this regard are also reviewed., (Copyright © 2010 Asian Surgical Association. Published by Elsevier B.V. All rights reserved.)

Aim: The study aimed to assess the outcome of live-donor liver transplantation for pediatric patients in a region with limited access to deceased donors., Patients and Methods: From September 1993 to September 2008, 78 pediatric patients aged between 73 days and 17 years (mean, 40 months) received 83 liver transplants. Sixty-two were living-related liver transplantations (LRLTs), and 21 were deceased-donor liver transplantations (DDLTs). The mean follow-up period was 6.5 years. The prospectively collected data of these patients were analyzed retrospectively., Results: The 1-, 2-, and 5-year survival rates of patients and grafts were 91%, 90%, 88% and 87%, 86%, 83%, respectively. The survival rates of LRLT patients and DDLT patients were 89%, 89%, 87%, and 90%, 86%, 86%, respectively (P = .58). The survival rates of patients aged 12 months or younger and patients older than 12 months were 95%, 92%, 90% and 90%, 90%, 87%, respectively (P = .65). One live donor developed temporary peroneal palsy, and another developed lung collapse (3%, 2/62). All live donors resumed their normal activities with no difficulty., Conclusion: With meticulous surgical techniques and postoperative care, it is justifiable to accept donated livers from voluntary live donors for transplantation to save pediatric patients in a place with scarce deceased donors.

The outcome of liver transplantation in China remains speculative. From 1998 to 2007, 177 adult Hong Kong patients underwent liver transplantation in China and were subsequently followed up at Queen Mary Hospital, Hong Kong. One hundred six (59.9%) patients had hepatocellular carcinoma (HCC). The grafts were probably derived from uncontrolled non-heart-beating donors. The 1-month mortality rate was 4.0%. The 1-, 3-, and 5-year overall survival rates were 73.9%, 59.0%, and 53.9%, respectively. The 5-year overall survival rates for non-HCC, HCC, HCC (within the Milan criteria), and HCC (beyond the Milan criteria) patients were 66.3%, 44%, 58%, and 26.2%, respectively. The long-term survival was compromised by the high incidence of HCC recurrence and graft failure secondary to diffuse intrahepatic biliary strictures. The overall survival rate of the entire group was lower than that of the patients receiving deceased donor liver grafts at Queen Mary Hospital in the same period. For non-HCC patients, however, the 5-year survival rate of 66.3% was comparable to that of recent reports from the Western world.

Background: The modified histology activity index (HAI) score has been extensively used as an additional primary or secondary end point in most phase III pivotal therapeutic clinical trials on chronic hepatitis B. Improvement in modified HAI after antiviral therapy has usually been defined as a 2-point reduction in modified HAI score., Aim: We studied whether a 2-point change in modified HAI score after antiviral therapy for chronic hepatitis B is associated with progression to liver complications (decompensated cirrhosis or hepatocellular carcinoma)., Method: Eighty-nine patients treated with interferon-alpha with liver biopsy before and at 6 to 12 months after the end of therapy were followed-up for a median 119.4 months., Results: At the time of analysis, 11 patients (12.4%) had liver complications. Liver complications were higher in patients with a 2-point increase in modified HAI score [8 of 19 patients (42.1%) vs. 3 of 70 patients (4.3%), P=0.0002] and in those with severe fibrosis at end of therapy [6 of 19 patients (31.6%) vs. 5 of 70 patients (7.1%), P=0.010]. On Cox regression analysis, a 2-point increase in modified HAI score was associated with increased liver complications (relative risk 5.564, P=0.036)., Conclusions: A 2-point increase in modified HAI score after antiviral therapy is associated with increased progression to liver complications.

Wilson disease (WD), an autosomal recessive disorder of copper transport, is the most common inherited liver disorder in Hong Kong Chinese. This was the first local study to elucidate the molecular basis and establish an effective DNA-based diagnostic protocol. The ATP7B genes of 65 patients were amplified by polymerase chain reaction (PCR) and sequenced. Haplotype analysis was performed using D13S301, D13S314, and D13S316. The p.L770L/p.R778L status in 660 subjects was determined to estimate WD prevalence. Allele age of p.R778L was determined by the smallest homozygosity region between D13S301 and D13S270. We identified 42 different mutations with 17 being novel. p.R778L (17.3%) was the most prevalent. Exons 2, 8, 12, 13, and 16 harbored 70% mutations. Thirty-two haplotypes were associated with WD chromosomes. The estimated prevalence rate was 1 in 5,400. Three out of 660 normal subjects had p.L770L/p.R778L. In the remaining 657 individuals, neither p.L770L nor p.R778L was found. We characterized a Hong Kong Chinese-specific ATP7B mutation spectrum with great genetic diversity. Exons 2, 8, 12, 13, and 16 should be screened first. The perfect linkage disequilibrium suggested that p.R778L and its private polymorphism p.L770L originated from a single ancestor. This East-Asian-specific mutation p.R778L/p.L770L is aged at least 5,500 years.

Background: Radiofrequency ablation (RFA) is an effective local ablation therapy for hepatocellular carcinoma (HCC) with favorable long-term outcome. There is no data on the analysis of recurrence pattern and its influence on long-term survival outcome after RFA in HCC patients., Aim of Study: To evaluate the tumor recurrence pattern and its influence on long-term survival in patients with HCC treated with RFA., Patients and Methods: From April 2001 to January 2005, 209 patients received RFA using internally cooled electrode as the sole treatment modality for HCC. Among them, 117 patients (56%) had unresectable HCC because of bilobar disease, poor liver function, and/or high medical risk for resection; whereas 92 patients (44%) underwent RFA as the primary treatment for small resectable HCC. The ablation procedure was performed through percutaneous (n=101), laparoscopic (n=17), or open approaches (n=91). The tumor recurrence pattern and long-term survival were analyzed. Multivariate analysis was carried out to identify independent prognostic factors affecting the overall survival of patients., Results: The mortality and morbidity rates were 0.9 and 15.7%, respectively. Complete tumor ablation was achieved in 192 patients (92.7%). With a median follow-up period of 26 months, local recurrence occurred in 28 patients (14.5%). Same segment and different segment intrahepatic recurrence occurred in 30 patients (15.6%) and 78 patients (40.6%), respectively. Twenty patients (10.4%) developed distant extrahepatic metastases. The overall 1-, 3-, and 5-year survival rates were 87.2, 66.6, and 42%, respectively. Different segment intrahepatic recurrence and distant recurrence after RFA carried significant poor prognostic influence on overall survival outcome. Using multivariate analysis, Child-Pugh grade (risk ratio [RR]=2.918, 95% confident interval [CI] 1.704-4.998, p=0.000), tumor size (RR=1.231, 95% CI 1.031-1.469, p=0.021), and pattern of recurrence (risk ratio [RR]=1.464, 95% CI 1.156-1.987, P=0.020) were identified as independent prognostic factors for overall survival., Conclusion: The tumor recurrence pattern after RFA carries significant prognostic value in relation to overall survival. Long-term regular surveillance and aggressive treatment strategy are required for patients with different segment intrahepatic recurrence to optimize the benefits of RFA.

Background: The molecular adsorbent recirculating system (MARS) is an extracorporeal liver dialysis system that allows selective removal of bilirubin and other albumin-bound toxins. We reported here our experience with the use of this technique for management of liver failure at Queen Mary Hospital, Hong Kong., Methods: From December 2002 to 2004, a total of 74 MARS sessions were performed on 22 patients. The cause of liver failure included acute liver failure (n = 2), acute on chronic liver failure (n = 12), posthepatectomy liver failure (n = 4), and posttransplantation allograft failure (n = 4)., Results: MARS treatment showed significant reduction in total bilirubin level, serum ammonia level and blood urea, and nitrogen (P < 0.001 for all three parameters). Five patients (22.7%) were able to bridge to transplantation and one patient (4.5%) made a spontaneous recovery. The 30-day mortality rate was 72.7%., Conclusions: Our results indicated that MARS can effectively improve serum biochemistry and is suitable for temporarily supporting patients with liver failure where transplantation is not immediately available. There is, however, no clear evidence showing that MARS can increase survival, improve the chance of transplantation or assist liver regeneration. Future studies in the form of randomized-controlled trials are crucial to characterize the true potential of this treatment.

Objective: Hepatocellular carcinoma (HCC) is common in Asia, and the majority are not suitable for curative surgical treatment. We studied the natural history of untreated nonsurgical HCC to examine whether the prognosis has changed with improved supportive treatment and to identify factors affecting survival., Methods: One hundred and six ethnic Chinese patients with HCC not amenable to curative treatment were managed symptomatically as control-arm patients in three randomized studies conducted between January 1996 and April 2001. Seventy-six (71.7%) patients were positive for hepatitis B surface antigen (HBsAg). Prognostic variables for survival were identified by univariate analysis and were subjected to a multivariate Cox analysis to identify the independent predictors of survival., Results: All but four patients were followed until death. Common causes of death were tumor progression (63.2%) and liver failure (31.1%). The overall median survival was 3 months, and the 1-yr survival was 7.8% only. The median survival of patients of Okuda stages I, II, and III were 5.1 months, 2.7 months, and 1.0 month, respectively (p < 0.05 for comparison between any two stages). Multivariate analysis revealed four independent prognostic variables, namely, serum bilirubin, blood urea, serum alpha-fetoprotein, and Okuda stage., Conclusions: The prognosis of untreated HCC not suitable for curative treatment in Asia is grave despite improved supportive treatment. The four prognostic variables identified in this study are important in the decision for palliative treatment, and the Okuda staging remains an important prognostic guide.

Background: Hepatocellular carcinoma (HCC) has an indisputable male predominance. "Gender" as an independent prognostic factor for survival is, however, controversial., Goals: Determine the influence of gender on survival in HCC patients, and identify factors that may account for the difference., Methods: A retrospective analysis on a prospectively collected database in a 15-year period, from 1989 to 2003., Results: A total of 3,171 HCC patients were managed in our institution (946 with curative treatment, 1,388 with palliative treatment, and 837 with supportive treatment) and studied. Female patients (n = 520) were 4.3 years older (P = 0.000), had a lower proportion of smokers and drinkers (P = 0.000), and were less likely to be hepatitis B carriers (P = 0.000). There was no difference in Child-Pugh status, tumor size, and the use of different treatments between genders. The overall median survival was 25.7 months longer in females after curative treatment (73.6 vs. 47.9 months; P = 0.012). The survival benefit in female patients was observed in early-stage diseases and persisted when only hepatitis B surface antigen-positive patients were analyzed (96.4 vs. 47.9 months; P = 0.044). With multivariate analysis, gender, indocyanine green test value at 15 minutes, number of tumor nodules, size of tumor, major vascular invasion, invasion of adjacent organs, and tumor rupture were the independent variables for survival. More importantly, in female patients, history of using oral contraceptive was an independent factor with survival benefit (P = 0.004)., Conclusion: Gender is an independent variable for survival after curative treatment of HCC. A survival benefit was observed in females. History of using oral contraceptive is associated with a better long-term survival in female patients.

Background: Laparoscopic cholecystectomy (LC) is now the procedure of choice for symptomatic gallbladder disease. Although many recent studies, mostly from abroad, report that it can be performed safely in the outpatient setting, the experience of outpatient LC in Hong Kong is still limited. This retrospective study evaluated the feasibility, safety and patient acceptance of outpatient LC in Hong Kong Chinese patients., Patients and Methods: The data of 73 consecutive patients who had undergone outpatient LC between February 2000 and October 2002 in the Day Surgery Centre of Tung Wah Hospital were prospectively collected and reviewed. The selection criteria for patients undergoing outpatient LC included American Society of Anesthesiologists risk classification I or II, age less than 70 years, and the availability of a competent adult to accompany the patient home and look after them for 24 hours. No effort was made to exclude complicated cases. After assessment by the operating surgeon, patients were discharged from the Day Surgery Centre in the afternoon when their clinical condition satisfied pre-defined discharge criteria. All patients were followed up in the Day Surgery Centre in the first and fourth postoperative weeks., Results: The same-day discharge rate was 88% and the conversion rate was 4%. Six patients (8.2%) with uneventful LC required hospitalization after the procedure. There was no major complication and no unplanned admission. Two patients had port site wound infection requiring hospital admission at the first follow-up. Patient satisfaction was high, pain acceptance was good, and analgesic consumption was minimal. Mild fat intolerance was common in patients postoperatively (> 50%), but this had almost all resolved by postoperative week four. All patients were able to resume their usual daily activities within 2 weeks after surgery., Conclusions: LC is a safe and feasible outpatient procedure in Hong Kong, with high levels of patient satisfaction. A prospective study with a larger patient population is warranted to verify whether it should be recommended as treatment for gallstone disease in selected patients in future.

Objective: To assess the trends in perioperative outcome of hepatectomy for hepatobiliary diseases., Methods: Data of 1222 consecutive patients who underwent hepatectomy for hepatobiliary diseases from July 1989 to June 2003 in a tertiary institution were collected prospectively. Perioperative outcome of patients in the first (group I) and second (group II) halves of this period was compared. Factors associated with morbidity and mortality were analyzed., Results: Diagnoses included hepatocellular carcinoma (n = 734), other liver cancers (n = 257), extrahepatic biliary malignancies (n = 43), hepatolithiasis (n = 101), benign liver tumors (n = 61), and other diseases (n = 26). The majority of patients (61.8%) underwent major hepatectomy of > or = 3 segments. The overall hospital mortality and morbidity were 4.9% and 32.4%, respectively. The number of hepatectomies increased from 402 in group I to 820 in group II, partly as a result of more liberal patient selection. Group II had more elderly patients (P = 0.006), more patients with comorbid illnesses (P = 0.001), and significantly worse liver function. Nonetheless, group II had lower blood loss (median 750 versus 1450 mL, P < 0.001), perioperative transfusion (17.3% versus 67.7%, P < 0.001), morbidity (30.0% versus 37.3%, P = 0.012), and hospital mortality (3.7% versus 7.5%, P = 0.004). On multivariate analysis, hypoalbuminemia, thrombocytopenia, elevated serum creatinine, major hepatic resection, and transfusion were the significant predictors of hospital mortality, whereas concomitant extrahepatic procedure, thrombocytopenia, and transfusion were the predictors of morbidity., Conclusions: Perioperative outcome has improved despite extending the indication of hepatectomy to more high-risk patients. The role of hepatectomy in the management of hepatobiliary diseases can be expanded. Reduced perioperative transfusion is the main contributory factor for improved outcome.

Background: Resection of a large hepatocellular carcinoma in the right liver or a small tumor located at the superior and posterior part of the right liver requires extensive hepatic mobilization. A thoracoabdominal approach might facilitate hepatic resection in such situations, but the safety and benefits of this approach remain unclear., Study Design: A retrospective study based on a prospectively collected database of 488 patients was performed to evaluate the perioperative outcomes of right-sided hepatic resection for hepatocellular carcinoma using the thoracoabdominal approach (n = 92) in comparison with the conventional abdominal approach (n = 396)., Results: The two groups were comparable in age, comorbid illnesses, liver function, tumor size, and underlying cirrhosis. There were more extended right hepatectomies in the thoracoabdominal approach group than in the abdominal approach group, but the difference was not significant (33.7% versus 26.0%, p = 0.14). A significantly higher proportion of patients in the thoracoabdominal approach group did not require blood transfusion compared with the abdominal approach group (66.3% versus 54.8%, p = 0.04). The operating time for the former group was longer (median 450 min versus 360 min, p < 0.001). There were no significant differences in hospital stay (median 12.5 days versus 13.0 days, p = 0.82), overall morbidity (41.3% versus 38.6%, p = 0.64), or hospital mortality (4.3% versus 7.3%, p = 0.37) between the two groups., Conclusions: The thoracoabdominal approach is a safe operative approach that can facilitate resection of massive tumors in the right liver or tumors involving segments 7 and 8 without increased morbidity., (Copyright 2003 by the American College of Surgeons)