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Current Issue

January - February, 2018

Vol. 17 Issue 1

On the cover: The Official Journal of the Mexican Association of Hepatology, the Latin-American Association for Study of the Liver and the Canadian Association for the Study of the Liver




  • The Changing Face of the Diagnosis of Chronic and Malignant Liver Diseases: Potential New Biomarkers Vania Cruz-Ramón, Paulina Chinchilla-López, Oscar Ramírez-Pérez, Xingshun Qi, Nahum Méndez-Sánchez Page 14-17

    The early diagnosis of primary sclerosing cholangitis, hepatocellular carcinoma, and cholangiocarcinoma is often challenging. In a recent study in 134 patients (Arbelaiz, Hepatology 2017; 66:1125-1143), it was reported that specific proteins found in serum extracellular vesicles of patients with primary sclerosing cholangitis, hepatocellular carcinoma,orcholangiocarcinomamay be useful as noninvasive diagnostic and prognostic tools. This current article critically appraises this study.


  • Meta-Analysis of Grazoprevir plus Elbasvir for Treatment of Hepatitis C Virus Genotype 1 Infection Hussien Ahmed, Abdelrahman Ibrahim Abushouk, Amr Menshawy, Attia Attia, Arwa Mohamed, Ahmed Negida, Mohamed M. Abdel-Daim Page 18-32

    Background and aim. Grazoprevir is an NS3/4A protease inhibitor (PI), while elbasvir is an NS5A inhibitor. We performed this meta-analysis to directly compare grazoprevir plus elbasvir and ribavirin regimen vs. grazoprevir and elbasvir without ribavirin in the treatment of hepatitis C virus genotype 1 infection and to precisely evaluate the efficacy of the latter regimen in cirrhotic, IL28 CC genotype patients and those coinfected with human immunodeficiency virus. Material and methods. A computer literature search of PubMed, Scopus, EBSCO, Embase, and Cochrane central was conducted. Studies were screened for eligibility. Sustained virologic response (SVR) rates were pooled using OpenMeta[Analyst] software for windows. A subgroup analysis was performed to stratify the treatment efficacy according to the different baseline characteristics of HCV patients. Results. Eight randomized controlled trials (n = 1,297 patients) were pooled in the final analysis. The overall SVR rate was 96.6% with 95% CI [95.5% to 98%]. For cirrhotic patients, the SVR rate was 95.7% with 95% CI [93.9% to 97.5%] and for non-cirrhotic patients, the SVR rate was 97% with 95% CI [95.9% to 98.4%]. Furthermore, the addition of ribavirin (RBV) to the treatment regimen did not significantly improve the SVR (RR 1.003, 95% CI [0.944 to 1.065]). The dual regimen was effective in patient populations with NS3 resistance-associated (RAS). However, this regimen achieved lower SVR rates (< 90%) in patients with NS5A RAS. Conclusions. We conclude that the 12-week treatment regimen of the fixed dose combination of grazoprevir plus elbasvir achieved high SVR rates in patients with HCV genotype 1 infection. The addition of ribavirin to this regimen did not add a significant benefit.

  • Hepatic Hydrothorax Yong Lv, Guohong Han, Daiming Fan Page 33-46

    Hepatic hydrothorax (HH) is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. Although the development of HH remains incompletely understood, the most acceptable explanation is that the pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm due to the raised abdominal pressure and the negative pressure within the pleural space. Patients with HH can be asymptomatic or present with pulmonary symptoms such as shortness of breath, cough, hypoxemia, or respiratory failure associated with large pleural effusions. The diagnosis is established clinically by finding a serous transudate after exclusion of cardiopulmonary disease and is confirmed by radionuclide imaging demonstrating communication between the peritoneal and pleural spaces when necessary. Spontaneous bacterial empyema is serious complication of HH, which manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. The mainstay of therapy of HH is sodium restriction and administration of diuretics. When medical therapy fails, the only definitive treatment is liver transplantation. Therapeutic thoracentesis, indwelling tunneled pleural catheters, transjugular intrahepatic portosystemic shunt and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality is high in these extremely ill patients.


Clinical Studies

Viral Hepatitis
  • Clinical Findings of HCV Chronic Infection in Undocumented Immigrants and Low-Income Refugees in Three Areas of Southern Italy Evangelista Sagnelli, Loredana Alessio, Caterina Sagnelli, Luciano Gualdieri, Mariantonietta Pisaturo, Carmine Minichini, Giovanni Di Caprio, Mario Starace, Lorenzo Onorato, Gaetano Scotto, Margherita Macera, Nicola Coppola Page 47-53

    Introduction and aim. In recent decades, Italy has become a land of immigration from countries suffering a socio-economic crisis. The aim of this study was to perform an organized screening to identify and offer care to immigrants with HCV infection. Material and methods. The screening, performed from 2012 to 2015, involved 1,727 immigrants in the Campania and Apulia regions in southern Italy. Results. Screening was accepted by 1,727 (85%) out of 2,032 immigrants interviewed; 70 (4.1%) of the 1,727 were anti-HCV-positive, all unaware of their serological condition, 31 (44.3%) of whom were HCV-RNA-positive and 39 negative. The 31 HCV-RNA-positive immigrants were further investigated at a third-level clinic of infectious diseases. The HCV viral load was 2.6 x 107 ± 7.7 x107 IU/mL, and 35.5% showed HCV-genotype 1a or 1b, 23.8% genotype 2 and 22.6% genotype 3. Two immigrants had liver cirrhosis and, in accordance with the Italian Healthcare Authority guidelines, received an interferon-free regimen and achieved a sustained virological response (SVR); 18 had chronic hepatitis, 6 of whom with a high risk of progression and received interferonbased therapy, with SVR in 4, whereas 12 at low risk were put on a waiting list for future interferon-free treatment, once licensed. The remaining 11 HCV-RNA-positive immigrants were considered HCV inactive chronic carriers and were included in a long-term observational program. Conclusion. The screening program can be considered successful since it was accepted by 85% of the subjects interviewed and identified 70 anti-HCV-positive immigrants, all unaware of their clinical and virological condition.

  • High Prevalence of Hepatitis B Subgenotype D4 in Northeast Brazil: an Ancient Relic from African Continent? Max D. Cruz-Santos, Michele S. Gomes-Gouvêa, Jomar D. Costa-Nunes, Camila Malta-Romano, Marinilde Teles-Sousa, Lena M. Fonseca-Barros, Flair J. Carrilho, Adalgisa de S. Paiva-Ferreira, João R. Rebello-Pinho Page 54-63

    Introduction. Hepatitis B virus (HBV) infection leads to a chronic liver disease that is distributed worldwide. The characterization of HBV into genotypes/subgenotypes is not only a mere procedure for distinguishing different HBV strains around the world because determining their geographic distribution is crucial to understanding their spread across the world. Material and methods. We characterized different HBV genotypes and subgenotypes in five municipalities located in northeastern Maranh�o, in the Brazilian north Atlantic coast. 92 HBsAg-positive individuals were submitted to PCR (polymerase chain reaction). Fifty samples were sequenced using automated Sanger sequencing and classified by phylogenetic methods. Results. Subgenotypes D4 and A1 were found in 42 (84%) and eight (16%) samples, respectively. To our knowledge, this is the first study to describe a high frequency of subgenotype D4 in any population. Subgenotype A1 is frequently found across Brazil, but D4 has been rarely detected and only in a few Brazilian states. This study shows the characterization of HBV subgenotypes from a population based study in the state of Maranh�o, particularly in populations that do not have frequent contact with populations from other regions of the world. Conclusion. Our findings showed a HBV subgenotype profile that probably reflect the viruses that were brought with the slave trade from Africa to Maranh�o. This study also reinforces the need to evaluate the status of HBV dispersion not only in large urban centers, but also in the hinterland, to enable the implementation of effective control and treatment measures.

  • Worsening of Serum Lipid Profile after Direct Acting Antiviral Treatment Stefano Gitto, Arrigo F. G. Cicero, Elisabetta Loggi, Marina Giovannini, Fabio Conti, Elena Grandini, Valeria Guarneri, Alessandra Scuteri, Giovanni Vitale, Carmela Cursaro, Claudio Borghi, Pietro Andreone Page 64-75

    Introduction. Host lipid metabolism influences viral replication and lifecycle of hepatitis C virus. Our aim was to evaluate changes in glucose and lipid metabolism of patients with chronic hepatitis C after therapy with direct acting antivirals (DAA). Material and methods. We considered patients consecutively treated between January and November 2015 recording clinical data at baseline and week 24 of follow-up. Frozen serum samples were used for apolipoprotein A1 (apoA1), apolipoprotein B (apoB) and lipoprotein (a) [Lp(a)]. Wilcoxon test was utilized to estimate trends and Logistic Regression for predictors of lipid changes. Results. We enrolled 100 patients, mostly cirrhotic (81%) and with genotype 1b (59%). Ninety-three patients achieved sustained virological response (SVR), while 7 relapsed. Homeostasis model assessment of insulin resistance declined (from 3 to 2.7, p < 0.001); non-high density lipoprotein (HDL) cholesterol increased from 102 ± 29 to 116 ± 35 (p < 0.001), and Lp(a) from 5.6 ± 6.5 to 9.8 ± 11.5 mg/dL (p < 0.001). Rise of low-density lipoprotein/HDL and apoB/apoA1 ratio were registered (from 1.79 ± 1.10 to 2.08 ± 1.05 and from 0.48 ± 0.18 to 0.53 ± 0.18 mg/dL, p < 0.001). We conducted a subanalysis on patients with relapse. In this subgroup, no change of lipid profile was recorded. At multivariate analysis emerged that the addition of ribavirin to DAA, represented an independent predictor of increased Lp(a) (OR 3.982, 95% CI 1.206-13.144, p = 0.023). Conclusion. DAA therapy led to reduction of insulin resistance. In contrast, pro-atherogenic lipid changes were observed in patients with SVR. Further studies will be necessary to evaluate the cardiovascular balance between amelioration of glucose metabolism and negative changes of lipid profile.

  • Recreational Drug and Psychosocial Profile in Chronic Hepatitis C Patients Seeking Antiviral Therapy Nayana George, Sherrie M. Harrell, Kimberly D. Rhodes, Andrés Duarte-Rojo Page 76-84

    Background and aims. Practitioners treating hepatitis C (HCV) provide healthcare to a special population with high rates of substance abuse and psychiatric disorders. We investigated the psychosocial profile in HCV patients and tested what variables affect commencement of antiviral therapy. Material and methods. Recreational drug use (RDU), marijuana (THC), alcohol use, and psychiatric history were initially investigated with a questionnaire prior to history and physical. Following an educational intervention, we reinterrogated patients for RDU and THC use, and revision of initial statement was documented. Variables affecting commencement of antiviral therapy were analysed with logistic regression. Results. Out of 153 patients, 140 (92%) answered the questionnaire. Intervention increased total yield by 6%, however, 39% (11/28) of those initially denying use revised their statement. Drug screening identified 9 more patients with RDU/THC use. Half of patients consuming alcohol were heavy drinkers, and psychiatric disease was identified in 54%. Only 73 (48%) of 139 patients eligible for antivirals received treatment. Multivariable analysis revealed that younger patients (OR = 1.04, 95% CI 1.01-1.08), and those testing positive on drug screen (OR = 0.41, 95% CI 0.19-0.92) were less likely to be treated. Denial by insurance and loss to follow-up were the most common reasons for not starting antiviral treatment. Conclusion. Substance abuse is highly prevalent among HCV patients, and it is difficult to tell prior from current users. Integral care of HCV patients should include a diligent screen for substance abuse and rehabilitation referral, aiming to increase the pool of patients eligible for antiviral therapy. This can only be achieved through a multidisciplinary approach.

Non alcoholic fatty liver disease (NAFLD)
  • Association of Adolescent Obesity with Nonalcoholic Fatty Liver Disease and Related Risk Factors in Xi'an, China Yan Rong, Niu Chun-Yan, Zhao Hong-Xin, Yu Lu, Wang Wen, Tian Yu Page 85-91

    Introduction and aim. To investigate the association of adolescent obesity with nonalcoholic fatty liver disease (NAFLD) and related risk factors in Xi 'an, China. Material and methods. A total of 4141 adolescents (2,061 girls and 2,080 boys, mean age: 18.62 ± 0.66 years, age range 15-22 years) were enrolled in this investigation. Anthropometric index was measured, and liver ultrasonography and liver function biochemical test were performed in all the subjects. T test, χ2 test and logistic regression analysis were used for statistical analyses. Results. The total rates of obesity was 7.9% (08/4,141). The prevalence rate of NAFLD was 8.1% (335/4141) with a declining trend from obesity, overweight to normal BMI. NAFLD prevalence rate in obese boys was significantly higher than in girls (χ2 = 56.5, P < 0.01). BMI, body weight, ALT, and AST in NAFLD group were higher than in non-NAFLD group (P < 0.05). The tangent point of ALT was 36 U/L using Youden index in boys, and 33 U/L in girls. Conclusion. The prevalence of obesity and NAFLD in adolescents is higher in Xi'an than anticipated. Body weight and BMI may be the associated independent risk factors of NAFLD.

Liver transplantation
  • Cultural Validation of the Transplanted Organ Questionnaire (TOQ) for the Brazilian Population Renata Medeiros, Rita Mattiello, Emmanuelle Corruble, Edgar E. Sarria, Cibele Molski, Ajácio Brandão Page 92-97

    Background and rationale. The Transplanted Organ Questionnaire (TOQ), developed in France, is a disease-targeted instrument designed to evaluate what the transplanted organ represents to the recipient in patients who have undergone liver transplantation. The present study sought to validate a version of the TOQ for use in the Brazilian population. Translation and cross-cultural adaptation were carried out in accordance with international standard practices. Convergent validity was measured by correlations between TOQ domains and the Beck Depression Inventory (BDI), while reliability was assessed by measurement of internal consistency (Cronbach's alpha coefficient), reproducibility (intraclass correlation coefficient), sensitivity to change (effect size), and floor and ceiling effects. Results. The study sample comprised 122 liver transplant recipients, with a mean age of 56.7 ± 9.9 years, treated at the outpatient clinic of a tertiary hospital in Southern Brazil. The sample was largely male (57.4%), and the predominant indication for liver transplant was hepatocellular carcinoma (34.4%). The mean total TOQ score was 32.9 ± 18.0. Cronbach's alpha for the total score was 0.89 (95%CI 0.86-0.92). Correlations between TOQ and BDI domains were acceptable, with the rejection domain correlating most strongly (r = 0.37; p ≤ 0.001). In conclusion, the Brazilian Portuguese version of the TOQ exhibited good psychometric performance, suggesting that it can be a useful tool in the Brazilian cultural context.

  • Exercise Capacity and Respiratory Profile in Patients after Orthopedic Liver Transplantation: a Follow-up Study Clarissa B. A. Magalhães, José Huygens P. Garcia, Cyntia F. G. Viana, Maria José N. Flor, Pedro Felipe C. de Bruin, Eanes D. B. Pereira Page 98-103

    Introduction: We sought to describe: 1) The influence of orthotopic liver transplantation (OLT) on exercise capacity, pulmonary function and respiratory muscle strength after surgery, 2) The relationship between exercise capacity and symptoms of anxiety and depression. Material and methods. This is a prospective follow up study conducted with patients submitted to OLT. All patients were assessed before and 1 month after surgery through measurements: six minute walk test (6MWT), 6 min step test (6MST) and HADS (Hospital Anxiety and Depression Scale). FEV1% (forced expiratory volume), maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured in the pre-operative and on 1st, 3rd, 5th day and 1 month after surgery. Results. In 77 patients , 6MWD improved 20.2 m (95%CI 8.1-32.3) and 6MST improved 7.8 steps after surgery (95%CI 3.9-11.6). Change in 6 MWD and 6 MST did not correlated with change HADS. The FEV1% at each time point were 88.8 ± 21.3 before surgery, 32.9 ± 9.9 on 1st day, 39.6 ± 11.5 on 3rd day, 46 ± 12.1 on 5th day and 86.6 ± 21.1 one month after surgery. MIP and MEP values at each time point were -67.4 ± 23.2 and 79.7 ± 26 before surgery, -30.8 ± 12.3 and 36.4 ± 15.4 on 1st day, -38.6 ± 14.1 and 43.8 ± 17 on 3rd day, -45.8 ± 15.9 and 49.7 ± 18.7 on 5th day and -67.1 ± 29.4 and 80.9 ± 23.9 one month after surgery. Conclusion. Exercise capacity was modestly increased after OLT without any correlation with symptoms of anxiety and depression. Pulmonary function and respiratory muscle strength decreased immediately after liver transplantation, and progressively recovered, returning to baseline values after 1 month.

  • The Portuguese Version of the Immunosuppressant Therapy Adherence Scale (ITAS) among Liver Transplant Recipient Patients: Translation and Psychometric Properties Ana Paula Jesus-Nunes, Mychelle Morais-de-Jesus, Adriana Dantas-Duarte, Tayne Miranda Moreira, Felipe Coelho Argolo, Alessandra de Oliveira Castro, Maria Auxiliadora Evangelista, Liana Codes, Paulo Lisboa Bittencourt, Lucas C. Quarantini Page 104-109

    Introduction and aim. Transplant recipients are chronically ill patients who rely on medical treatment throughout life to achieve positive results. Despite that, medication nonadherence after liver transplantation is extremely common. The self-report, one of several methods for measuring adherence, is easy to apply and low cost. Thus, this study aims to translate and validate the Immunosuppressant Therapy Adherence Instrument (ITAS) in Brazilian Portuguese for liver transplant recipients. Material and methods. A total of 139 liver transplant recipients were selected from a general hospital, who were assessed by using the Portuguese version of ITAS. The scale was translated based on the model proposed by Wild, et al. and its psychometric properties were assessed. Results. The average Cronbach's α coefficient was 0.830. ITAS and Basel Assessment of Adherence with Immunosuppressive Medications Scale (BAASIS) presented significant correlation, with a Spearman's ρ coefficient = 0.300 (S = 309,580; p < 0.001). The area under the receiver operating characteristics (ROC) curve was 0.638 (95% CI: 0.557 - 0.715). Factor analysis results indicated that the carelessness factor model was the optimal model, and the factor "feeling worse" was the lowest. Conclusion. The Portuguese version of ITAS has adequate psychometric properties to measure adherence to immunosuppressant therapy.

Hepatocellulary Malignancies
  • Prognostic ability of BCLC-B Subclassification in Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization Marco Biolato, Giulia Gallusi, Massimo Iavarone, Giuseppe Cabibbo, Simona Racco, Adriano De Santis, Cristina della Corte, Marcello Maida, Adolfo Francesco Attili, Angelo Sangiovanni, Calogero Cammà, Giuseppe La Torre, Antonio Gasbarrini, Antonio Grieco Page 110-118

    Background and aims. A subclassification system for intermediate hepatocellular carcinoma (HCC) was recently proposed to optimize treatment allocation. The aim of this study was to assess the prognostic ability of that substaging proposal. Patients and methods. This is a retrospective multicenter cohort study including patients with intermediate HCC treated with transarterial chemoembolization (TACE). Predictors of survival were identified using the Cox proportional regression model. Results. 289 Barcelona Clinic Liver Cancer (BCLC) B patients were included. Median overall survival of the whole cohort was 23 months (C.I. 95% 20.2-25.8). Child A status (H.R. 1.35, C.I. 95% 1.02-1.78) and tumour burden beyond the up-to-seven criterion (H.R. 1.39, C.I. 95% 1.07-1.80) were independent prognostic factors for overall survival on multivariate analysis. Analysis of the substages showed that median survival was 33.0 months for B1 stage (n = 81), 20.8 months for B2 stage (n = 106), 16.1 months for B3 stage (n = 24), 22.2 months for B4 stage (n = 42) and 15.0 months for quasi-C stage (n = 36). Regarding the discriminatory ability of the substaging proposal, the log rank test showed a significant survival difference for B1vs. B4 (p = 0.003) and B1 vs. Quasi-C (p = 0.039) and a trend for B1 vs. B2 (p = 0.05) and B1 vs. B3 (p = 0.05). Conclusions. Apart from substage B1, BCLC-B subclassification does not discriminate perfectly patients treated with TACE. Also some patients in substage B4 can benefit from TACE.

  • Risk and Prognosis of Acute Liver Injury Among Hospitalized Patients with Hemodynamic Instability: A Nationwide Analysis Najeff Waseem, Berkeley N. Limketkai, Brian Kim, Tinsay Woreta, Ahmet Gurakar, Po-Hung Chen Page 119-124

    Introduction and aim. Critically ill patients in states of circulatory failure are at risk of acute liver injury, from mild elevations in aminotransferases to substantial rises consistent with hypoxic hepatitis or ?shock liver?. The present study aims to quantify the national prevalence of acute liver injury in patients with hemodynamic instability, identify risk factors for its development, and determine predictors of mortality. Material and methods. The 2009-2010 Nationwide Inpatient Sample was interrogated using ICD-9-CM codes for hospital admissions involving states of hemodynamic lability. Multivariable logistic regression was used to evaluate the risks of acute liver injury and death in patients with baseline liver disease, congestive heart failure, malnutrition, and HIV. Results. Of the 2,865,446 patients identified in shock, 4.60% were found to have acute liver injury. A significantly greater proportion of patients with underlying liver disease experienced acute liver injury (22.03%) and death (28.47%) as compared to those without liver disease (3.18% and 18.82%, respectively). The odds of developing acute liver injury were increased in all baseline liver diseases studied, including all-cause cirrhosis, hepatitis B, hepatitis C, alcoholic liver disease, and non-alcoholic fatty liver disease, as well as in congestive heart failure and malnutrition. All-cause cirrhosis and alcoholic liver disease, however, conferred the greatest risk. Similar trends were seen with mortality. HIV was not a predictor for acute liver injury. Conclusion. Liver injury is a major concern among patients with protracted circulatory instability, especially those suffering from underlying liver disease, heart failure, or malnutrition.

  • Acute Variceal Bleeding: Does Octreotide Improve Outcomes in Patients with Different Functional Hepatic Reserve? Roberto Monreal-Robles, Carlos A. Cortéz-Hernández, José A. González-González, Juan G. Abraldes, Francisco J. Bosques-Padilla, Héctor N. Silva-Ramos, Jorge A. García-Flores, Héctor J. Maldonado-Garza Page 125-133

    Background. Current guidelines do not differentiate in the utilization of vasoactive drugs in patients with cirrhosis and acute variceal bleeding (AVB) depending on liver disease severity. Material and methods. In this retrospective study, clinical outcomes in 100 patients receiving octreotide plus endoscopic therapy (ET) and 216 patients with ET alone were compared in terms of failure to control bleeding, in-hospital mortality, and transfusion requirements stratifying the results according to liver disease severity by Child-Pugh (CP) score and MELD. Results. In patients with CP-A or those with MELD < 10 octreotide was not associated with a better outcome compared to ET alone in terms of hospital mortality (CP-A: 0.0 vs. 0.0%; MELD < 10: 0.0 vs. 2.9%, p = 1.00), failure to control bleeding (CP-A: 8.7 vs. 3.7%, p = 0.58; MELD < 10: 5.3 vs. 4.3%, p = 1.00) and need for transfusion (CP-A: 39.1 vs. 61.1%, p = 0.09; MELD < 10: 63.2 vs. 62.9%, p = 1.00). Those with severe liver dysfunction in the octreotide group showed better outcomes compared to the non-octreotide group in terms of hospital mortality (CP-B/C: 3.9 vs. 13.0%, p = 0.04; MELD ≥ 10: 3.9 vs. 13.3%, p = 0.03) and need for transfusion (CP-B/C: 58.4 vs. 71.6%, p = 0.05; MELD ≥ 10: 50.6 vs. 72.7%, p < 0.01). In multivariate analysis, octreotide was independently associated with in-hospital mortality (p = 0.028) and need for transfusion (p = 0.008) only in patients with severe liver dysfunction (CP-B/C or MELD ≥ 10). Conclusion. Patients with cirrhosis and AVB categorized as CP-A or MELD < 10 had similar clinical outcomes during hospitalization whether or not they received octreotide.

  • Short- and Long-term Outcomes between Young and Older HCC Patients Exceeding The Milan Criteria after Hepatectomy Junyi Shen, Chuan Li, Lvnan Yan, Bo Li, Mingqing Xu, Jiayin Yang, Wentao Wang, Tianfu Wen Page 134-143

    Aim. The objective of this study was to evaluate short- and long-term survival after surgical treatment between young and older hepatocellular carcinoma (HCC) patients beyond the Milan criteria. Material and methods. One hundred fifty-seven HCC patients (≤ 55 years old) were categorized into group A, and one hundred fifty-eight HCC patients (> 55 years old) were categorized into group B. Postoperative complications and overall survival were retrospectively analyzed. Results. Older HCC patients had a higher rate of delayed extubation after surgery and suffered more complications after surgery, especially major complications. Intraoperative blood transfusion, liver fibrosis/cirrhosis and delayed extubation were risk factors related to postoperative complications. Microvascular invasion (MVI), tumor diameter, postoperative alpha-fetoprotein and the presence of satellites were independent risk factors for long-term survival. Young patients had more advanced tumors. Overall survival rates at 1, 3 and 5-years were 78.1%, 45.1% and 27.4% for young patients, respectively, and 86.5%, 57.5% and 42.4% for older patients, respectively (p = 0.007). Conclusion. The category A group had poorer tumor characteristics and worse prognoses than the category B group.

Basic studies

  • Hypericum Humifusum Leaves Attenuates Hepatic Ischemia-Reperfusion Injury in a Rat Model Henda Ferchichi, Issam Salouage, Sarra Bacha, Nadia Kourda, Nadia Jebabli, Emna Gaies, Anis Klouz, Sameh Trabelsi Page 144-152

    Introduction. Effective prevention strategies require specific actions during the different phases of ischemia-reperfusion (I-R) injury. The objective of our study is to evaluate the effect of aqueous extract of Hypericum humifusum leaves (HHL) on liver I-R model in Rat. Material and methods. Animals were subjected to 90 min of hepatic ischemia followed by reperfusion (120 min). HHL extract (25 mg/mL/kg) was injected 15 min before reperfusion. To evaluate the effect of HHL extract on I-R, we have monitored transaminases levels, Malondialdehyde (MDA) concentration, histological lesions (apoptosis and necrosis) and compared the results to a reference oxidant vitamin E. Results. The determination of total phenol extracts of HHL was 59.91 ± 0.35 mg of Gallic Acid/g dry plant material with higher antioxidant activity (91.73% ± 1.67) compared to vitamin E (87.42%). Using aqueous extract of HHL, we noted a significant decrease of AST and ALT [1129 UI (585/1995) and 768 UI (335/1375)] compared to no-treated group [5,585.5 UI (5,035/12,070) and 8,099.5 UI (5,040/12,326)] as a decrease in MDA content [85.7% protection (50.9/91.5)]. HHL extract reduce the damage induced by I-R of 48.7% (27/48.7) and 96.1% (95.7/96.5) for necrosis and apoptosis lesions respectively. Conclusion. HHL aqueous extract have potential to protect liver from the damage effect induced by I-R better than vitamin E solution.

  • Efficacy of Probiotics and Smectite in Rats with Non-Alcoholic Fatty Liver Disease Nazarii Kobyliak, Ludovico Abenavoli, Tetyana Falalyeyeva, Tetyana Beregova Page 153-161

    Introduction and aim. Today probiotics have been suggested as a treatment for the prevention of non-alcoholic fatty liver disease (NAFLD). Smectite is a natural silicate that binds to digestive mucous and has the ability to bind endo- and exotoxins. The present study was designed to determine whether probiotics plus smectite is superior to probiotic alone on the monosodium glutamate (MSG) induced NAFLD model in rats. Materials and methods. We included 60 rats divided into 4 groups 15 animals in each. Rats of group I were intact. Newborns rats of groups II-IV were injected with MSG. The III (Symbiter) group received 2.5 ml/kg of multiprobiotic 'Symbiter' containing concentrated biomass of 14 probiotic bacteria genera. The IV (Symbiter+Smectite) groups received 'Symbiter Forte' combination of probiotic biomass with smectite gel (250 mg). Results. In both interventional groups reduction of total NAS score as compared to MSG-obesity was observed. Indeed similar values of steatosis score (0.93 ± 0.22 vs. 0.87 ± 0.16) in both treatment groups, we observed that lower total score for Symbiter+ Smectite are associated with more pronounced reduction of lobular inflammation (0.13 ± 0.09 vs. 0.33 ± 0.15) as compared to administration of probiotic alone. This data accompanied with significant reduction of IL-1 and restoration of IL-10 between these 2 groups. Conclusions. Additional to alive probiotic administration of smectite gel due to his absorbent activity and mucus layer stabilization properties can impact on synergistic enhancement of single effect which manifested with reduction of lobular inflammation and at list partly steatohepatitis prevention.


  • Atypical Abdominal Pain in a Patient With Liver Cirrhosis Liz Toapanta-Yanchapaxi, Eid-Lidt Guering, Ignacio García-Juárez Page 162-164

    The causes of abdominal pain in patients with liver cirrhosis and ascites are well-known but occasionally, atypical causes arise. We report the case of a patient with a ruptured, confined abdominal aortic aneurysm.


  • Hepatic Cyst Compressing The Right Atrial and Ventricular Inflow Tract: An Uncommon Cardiac Complication Maulik Panchal, Ahmed Alansari, Marc Wallack, Ferdinand Visco, Susan Williams, Alexander M. Sy Page 165-168

    Commonly reported complications of hepatic cysts are spontaneous hemorrhage, rupture into the peritoneal cavity, infection and compression of the biliary tree however cardiac complications are not commonly reported. We are presenting a case of a large liver cyst presenting with right atrial and ventricular inflow tract impingement resulting in cardiac symptoms. A 68 year-old Hispanic female presented with one month of fatigue and shortness of breath after household work and walking less than one block, right upper quadrant pain and weight loss. She had history of multiple hepatic cysts for more than 12 years, well-controlled diabetes and hypertension. Examination of the heart revealed tachycardia with regular heart sounds. There were no murmurs. She had tenderness in her right upper quadrant on palpation and an enlarged smooth liver. Rest of physical examination was unremarkable. CT scan of the abdomen showed multiple non-enhancing liver cysts in both lobes, with the largest measuring 12 x 15 x 17 cm which was significantly increased from her baseline of 7 x 8 x 10 cm in 2003. Echocardiogram showed normal left ventricular ejection fraction, grade 1 diastolic dysfunction and a hepatic cyst impinging RA and RV inflow tract. She had successful laparoscopic enucleation of liver cyst and subsequent relief from tachycardia, fatigue and shortness of breath. In conclusion, this case illustrates that hepatic cysts may become symptomatic after remaining quiescent for an extended period. They may present with unusual symptoms and clinicians should be mindful of rare complications, such as in this case.

  • Pyogenic Liver Abscess Secondary to Foreign Body (Fish Bone) Treated by Laparoscopy: A Case Report Renato G. Bandeira-de-Mello, Gabriel Bondar, Eduardo Schneider, Isabel Cristina Wiener-Stensmann, Juliano Bohrer Gressler, Cleber Rosito Pinto Kruel Page 169-173

    Liver abscess due to perforation of the gastrointestinal tract by a foreign body is a rare and possibly fatal event. Diagnosing this pathology is complicated by the lack of specific symptoms and unfamiliarity of ingestion by the patient and low clinical suspicion of this disease. In the case of liver abscess unresponsive to aspiration and administration of antibiotics, this hypothesis must be made, despite its low incidence. This case report describes and illustrates a case of liver abscess secondary to fish bone ingestion with consequent piercing of the lesser gastric curvature, diagnosed by computed tomography and specific anamnesis. Laparoscopy was performed to extract the foreign body, without complications; the patient is currently asymptomatic and does not present any abnormal physical examination findings. We believe this represents the first case report of a successful laparoscopic treatment in South America for the removal of an ingested foreign body associated with pyogenic liver abscess.


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