Various treatment modalities are available for small solitary hepatocellular carcinoma (HCC), yet the optimal primary treatment strategy for tumors ≤ 3 cm remains unclear. This network meta-analysis investigates the comparative efficacy of various interventions on the long-term outcomes of patients with solitary HCC ≤ 3 cm. A systematic search of electronic databases from January 2000 to December 2023 was conducted to identify studies that compared at least two of the following treatments: surgical resection (SR), radiofrequency ablation (RFA), microwave ablation (MWA), and transarterial chemoembolization (TACE). Survival data were extracted, and pooled hazard ratios with 95% confidence intervals were calculated using a frequentist network meta-analysis. A total of 30 studies, comprising 2 randomized controlled trials and 28 retrospective studies, involving 8,053 patients were analyzed. Surgical resection showed the highest overall survival benefit with a p-score of 0.95, followed by RFA at 0.59, MWA at 0.23, and TACE, also at 0.23. Moreover, SR provided the most significant recurrence-free survival advantage, with a p-score of 0.95, followed by RFA at 0.31 and MWA at 0.19. Sensitivity analyses, excluding low-quality or retrospective non-matched studies, corroborated these findings. This network meta-analysis demonstrates that SR is the most effective first-line curative treatment for single HCC ≤ 3 cm, followed by RFA in patients with preserved liver function. The limited data on MWA and TACE underscore the need for further studies.

Various treatment modalities are available for small solitary hepatocellular carcinoma (HCC), yet the optimal primary treatment strategy for tumors ≤ 3 cm remains unclear. This network meta-analysis investigates the comparative efficacy of various interventions on the long-term outcomes of patients with solitary HCC ≤ 3 cm. A systematic search of electronic databases from January 2000 to December 2023 was conducted to identify studies that compared at least two of the following treatments: surgical resection (SR), radiofrequency ablation (RFA), microwave ablation (MWA), and transarterial chemoembolization (TACE). Survival data were extracted, and pooled hazard ratios with 95% confidence intervals were calculated using a frequentist network meta-analysis. A total of 30 studies, comprising 2 randomized controlled trials and 28 retrospective studies, involving 8,053 patients were analyzed. Surgical resection showed the highest overall survival benefit with a p-score of 0.95, followed by RFA at 0.59, MWA at 0.23, and TACE, also at 0.23. Moreover, SR provided the most significant recurrence-free survival advantage, with a p-score of 0.95, followed by RFA at 0.31 and MWA at 0.19. Sensitivity analyses, excluding low-quality or retrospective non-matched studies, corroborated these findings. This network meta-analysis demonstrates that SR is the most effective first-line curative treatment for single HCC ≤ 3 cm, followed by RFA in patients with preserved liver function. The limited data on MWA and TACE underscore the need for further studies.

Various treatment modalities are available for small solitary hepatocellular carcinoma (HCC), yet the optimal primary treatment strategy for tumors ≤ 3 cm remains unclear. This network meta-analysis investigates the comparative efficacy of various interventions on the long-term outcomes of patients with solitary HCC ≤ 3 cm. A systematic search of electronic databases from January 2000 to December 2023 was conducted to identify studies that compared at least two of the following treatments: surgical resection (SR), radiofrequency ablation (RFA), microwave ablation (MWA), and transarterial chemoembolization (TACE). Survival data were extracted, and pooled hazard ratios with 95% confidence intervals were calculated using a frequentist network meta-analysis. A total of 30 studies, comprising 2 randomized controlled trials and 28 retrospective studies, involving 8,053 patients were analyzed. Surgical resection showed the highest overall survival benefit with a p-score of 0.95, followed by RFA at 0.59, MWA at 0.23, and TACE, also at 0.23. Moreover, SR provided the most significant recurrence-free survival advantage, with a p-score of 0.95, followed by RFA at 0.31 and MWA at 0.19. Sensitivity analyses, excluding low-quality or retrospective non-matched studies, corroborated these findings. This network meta-analysis demonstrates that SR is the most effective first-line curative treatment for single HCC ≤ 3 cm, followed by RFA in patients with preserved liver function. The limited data on MWA and TACE underscore the need for further studies.

The population with obesity is seeing a steady increase globally. Obesity is known to be associated with morbidity and mortality after major abdominal surgery, and this correlation becomes more prominent in morbidly obese (MO) patients. Accordingly, adequate preoperative evaluation and preparation should be performed with an understanding of the pathophysiological changes associated with the MO. Precise surgery and adequate postoperative management are also mandatory to reduce complications and unplanned readmissions. However, adequate guidelines for the perioperative management of MO patients undergoing major abdominal surgery are lacking. We provide an overview of the pathophysiologic changes and practical guidelines on the perioperative management of major abdominal surgery in MO patients.

Purpose: When splitting a liver for adult and pediatric graft recipients, the retained left medial section (S4) will undergo ischemic necrosis and the right trisection graft becomes an extended right liver (ERL) graft. We investigated the fates of the retained S4 and its prognostic impact in adult split liver transplantation (SLT) using an ERL graft. Methods: This was a retrospective analysis of 25 adult SLT recipients who received split ERL grafts. Results: The mean model for end-stage liver disease (MELD) score was 27.3 ± 10.9 and graft-recipient weight ratio (GRWR) was 1.98 ± 0.44. The mean donor age was 26.5 ± 7.7 years. The split ERL graft weight was 1,181.5 ± 252.8 g, which resulted in a mean GRWR of 1.98 ± 0.44. Computed tomography of the retained S4 parenchyma revealed small ischemic necrosis in 16 patients (64.0%) and large ischemic necrosis in the remaining 9 patients (36.0%). No S4-associated biliary complications were developed. The mean GRWR was 1.87 ± 0.43 in the 9 patients with large ischemic necrosis and 2.10 ± 0.44 in the 15 cases with small ischemic necrosis (P = 0.283). The retained S4 parenchyma showed gradual atrophy on follow-up imaging studies. The amount of S4 ischemic necrosis was not associated with graft (P = 0.592) or patient (P = 0.243) survival. A MELD score of >30 and pretransplant ventilator support were associated with inferior outcomes. Conclusion The amount of S4 ischemic necrosis is not a prognostic factor in adult SLT recipients, probably due to a sufficiently large GRWR.

Purpose: When splitting a liver for adult and pediatric graft recipients, the retained left medial section (S4) will undergo ischemic necrosis and the right trisection graft becomes an extended right liver (ERL) graft. We investigated the fates of the retained S4 and its prognostic impact in adult split liver transplantation (SLT) using an ERL graft. Methods: This was a retrospective analysis of 25 adult SLT recipients who received split ERL grafts. Results: The mean model for end-stage liver disease (MELD) score was 27.3 ± 10.9 and graft-recipient weight ratio (GRWR) was 1.98 ± 0.44. The mean donor age was 26.5 ± 7.7 years. The split ERL graft weight was 1,181.5 ± 252.8 g, which resulted in a mean GRWR of 1.98 ± 0.44. Computed tomography of the retained S4 parenchyma revealed small ischemic necrosis in 16 patients (64.0%) and large ischemic necrosis in the remaining 9 patients (36.0%). No S4-associated biliary complications were developed. The mean GRWR was 1.87 ± 0.43 in the 9 patients with large ischemic necrosis and 2.10 ± 0.44 in the 15 cases with small ischemic necrosis (P = 0.283). The retained S4 parenchyma showed gradual atrophy on follow-up imaging studies. The amount of S4 ischemic necrosis was not associated with graft (P = 0.592) or patient (P = 0.243) survival. A MELD score of >30 and pretransplant ventilator support were associated with inferior outcomes. Conclusion The amount of S4 ischemic necrosis is not a prognostic factor in adult SLT recipients, probably due to a sufficiently large GRWR.

Purpose: Epithelioid hemangioendothelioma (EHE) is a rare borderline vascular tumor. This retrospective, single-center study evaluated the outcomes of hepatic resection (HR) in patients with hepatic EHE. Methods: Over the 10-year period from 2009 to 2018, 11 patients with hepatic EHE underwent HR, accounting for 0.1% of the 11,979 adults who underwent HR at our center. Diagnosis of hepatic EHE was confirmed by immunohistochemical staining for CD34, CD31, and factor VIII-related antigen. Results: The 11 patients included 9 females (81.8%) and 2 males (18.2%) with mean age of 43.5 ± 13.6 years. Preoperative imaging resulted in a preliminary diagnosis of suspected liver metastasis or EHE, with 9 patients (81.8%) undergoing liver biopsy. No patient presented with abnormally elevated concentrations of liver tumor markers. The extents of HR were determined by tumor size and location from trisectionectomy to partial hepatectomy. All patients recovered uneventfully from HR. Five patients showed tumor recurrence, with 4 receiving locoregional treatments for recurrent lesions. The 1-, 3-and 5-year disease-free survival rates were 90.9%, 54.5%, and 54.5%, respectively. Currently, all patients remain alive and are doing well. Univariate analysis on tumor recurrence showed that tumor size ≥ 4 cm was significantly associated with tumor recurrence (P = 0.032), but tumor number ≥ 4 was not related to (P = 0.24). Conclusion Hepatic EHE is a rare form of primary liver tumor often misdiagnosed as a metastatic tumor. Because of its malignant potential, HR is indicated if possible. HR plus, when necessary, treatment of recurrence yields favorable overall survival rates in patients with hepatic EHE.

Purpose: Recent clinical trials have successfully used oral immunotherapy (OIT) to treat food allergies. Probiotics have immunomodulatory effects by balancing Th1/Th2 immunity and enhancing regulatory T-cell activity. In this study, we analyzed the effects of OIT, probiotics alone, and probiotics administered simultaneously with OIT in a mouse model of egg allergy. Methods: C3H/HeJ mice were sensitized by intragastric administration of ovomucoid (OM) with cholera toxin. For the OIT regime, increasing doses of OM were administered orally to sensitized mice. Lactobacillus casei variety ramnosus (Lcr35) was also administered. The mice were divided into 4 groups: control (no OIT), OIT, Lcr35, and OIT plus Lcr35 (OIT + Lcr35). The effects of OIT and Lcr35 treatment were estimated based on the symptom score, rectal temperature, serum levels of OM-specific immunoglobulin (Ig)E, IgA, IgG1, and IgG2a immediately after and 2 weeks after ceasing treatment and histological staining of the small intestine. Results: The severity of anaphylaxis decreased in all treatment groups. Simultaneous administration of Lcr35 and OIT decreased the severity of anaphylaxis compared to controls and the OIT group. The protective effects were sustained 2 weeks after ceasing treatment in all treatment groups. A significant decrease in OM-specific IgA, IgG1, and IgG2a levels was observed in both the OIT and OIT plus Lcr35 groups. However, a significant decrease in the OM-specific IgE level was observed only in OIT plus Lcr35 treated mice and was sustained 2 weeks after ceasing treatment. Mucin amounts in the small intestine decreased after OIT, OIT plus Lcr35, and Lcr35 treatment with the lowest in the OIT plus Lcr35 group. Conclusions Lcr35 treatment during OIT had some synergic effect for protection against anaphylaxis in a mice model of egg allergy. These findings should be confirmed in future animal studies including more detailed immunological profiles and human studies.

Purpose: Recent clinical trials have successfully used oral immunotherapy (OIT) to treat food allergies. Probiotics have immunomodulatory effects by balancing Th1/Th2 immunity and enhancing regulatory T-cell activity. In this study, we analyzed the effects of OIT, probiotics alone, and probiotics administered simultaneously with OIT in a mouse model of egg allergy. Methods: C3H/HeJ mice were sensitized by intragastric administration of ovomucoid (OM) with cholera toxin. For the OIT regime, increasing doses of OM were administered orally to sensitized mice. Lactobacillus casei variety ramnosus (Lcr35) was also administered. The mice were divided into 4 groups: control (no OIT), OIT, Lcr35, and OIT plus Lcr35 (OIT + Lcr35). The effects of OIT and Lcr35 treatment were estimated based on the symptom score, rectal temperature, serum levels of OM-specific immunoglobulin (Ig)E, IgA, IgG1, and IgG2a immediately after and 2 weeks after ceasing treatment and histological staining of the small intestine. Results: The severity of anaphylaxis decreased in all treatment groups. Simultaneous administration of Lcr35 and OIT decreased the severity of anaphylaxis compared to controls and the OIT group. The protective effects were sustained 2 weeks after ceasing treatment in all treatment groups. A significant decrease in OM-specific IgA, IgG1, and IgG2a levels was observed in both the OIT and OIT plus Lcr35 groups. However, a significant decrease in the OM-specific IgE level was observed only in OIT plus Lcr35 treated mice and was sustained 2 weeks after ceasing treatment. Mucin amounts in the small intestine decreased after OIT, OIT plus Lcr35, and Lcr35 treatment with the lowest in the OIT plus Lcr35 group. Conclusions Lcr35 treatment during OIT had some synergic effect for protection against anaphylaxis in a mice model of egg allergy. These findings should be confirmed in future animal studies including more detailed immunological profiles and human studies.

Background: Split liver transplantation (SLT) has been occasionally performed in Korea. This study compared the incidence and prognosis of SLT with whole liver transplantation (WLT) in adult patients. Methods: Between June 2016 and November 2019, 242 adult patients underwent a total of 256 deceased donor liver transplantation operations. SLT was performed in 7 patients (2.9%). Results: The mean age of SLT donors was 29.7 ± 7.4 years, and the mean age of recipients was 55.7 ± 10.6 years, with the latter having a mean model for end-stage liver disease score of 34.6 ± 3.1. Mean split right liver graft weight was 1,228.6 ± 149.7 g and mean graft-recipient weight ratio was 1.97 ± 0.39. Of the seven SLT recipients, Korean Network for Organ Sharing (KONOS) status was one in status 1, one in status 2 and five in status 3. The graft (p = 0.72) and patient (p = 0.84) survival rates were comparable in the SLT and WLT groups. Following propensity score matching, graft (p = 0.61) and patient (p = 0.91) survival rates remained comparable in the two groups. Univariate analysis showed that pretransplant ventilator support and renal replacement therapy were significantly associated with patient survival, whereas KONOS status category and primary liver diseases were not. Multivariate analysis showed that pretransplant ventilator support was an independent risk factor for patient survival. Conclusion Survival outcomes were similar in adult SLT and WLT recipients, probably due to selection of high-quality grafts and low-risk recipients. Prudent selection of donors and adult recipients for SLT may expand the liver graft pool for pediatric patients without affecting outcomes in adults undergoing SLT.