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Open access

Michał Grąt, Wacław Hołówko, Karolina Grzegorczyk, Michał Skalski and Marek Krawczyk

Long-Term Results of Liver Resection in the Treatment of Patients with Hepatocellular Carcinoma

The aim of the study was the analysis of the results of liver resection in the treatment of patients with hepatocellular carcinoma, taking into consideration the selected factors based on the department's material.

Material and methods. Data of 122 patients subject to liver resection due to hepatocellular carcinoma at the Department of General, Transplantation and Liver Surgery, Medical University of Warsaw, were subject to retrospective analysis.

The influence of selected factors on the long-term treatment results was determined, and the patient survival depending on the tumor stage as per the TNM scale was compared. The statistical significance threshold was set at p = 0.05.

Results. 1- and 3-year overall survival and recurrence-free survival in the whole patient group was 82.1% and 56.3%, and 57.7% and 20.1%, respectively. The perioperative mortality rate was 1.6%. The neoplasm advancement exceeding the first stage on the TNM scale was associated with lower values of overall survival (p = 0.001, HR = 3.7) and recurrence-free survival (p = 0.00008, HR = 3.8). Elevation of AFP was the only independent prognostic factor for overall survival (p = 0.04, HR = 1.04 at alpha-fetoprotein levels > 1000 ng/ml), while the presence of neoplastic emboli in small blood vessels was an independent risk factor for HCC recurrence (p = 0.02, HR = 2.24).

Conclusions. The alpha-fetoprotein levels and presence in the histopathological examination of neoplastic emboli in small blood vessels are independent prognostic factors for outcome of patients operated for hepatocellular carcinoma. The diagnosis of neoplasm at stage 1 as per TNM significantly improves long-term results of resective treatment.

Open access

Michał Grąt, Oskar Kornasiewicz, Karolina Grąt, Arkadiusz Antczak, Joanna Ligocka, Wacław Hołówko, Karolina Maria Wronka, Konrad Kobryń, Michał Skalski, Leszek Pączek and Marek Krawczyk

Abstract

The number of elderly patients undergoing liver transplantation (LT) is increasing worldwide.

The aim of the study was to evaluate the impact of recipient age exceeding 60 years on early and long-term outcomes after LT.

Material and methods. This study comprised data of 786 patients after primary LT performed at a single center between January 2005 and October 2012. Patients over and under 60 years of age were compared with respect to baseline characteristics and outcomes: postoperative mortality (90-day) and 5-year patient (PS) and graft (GS) survival. Associations between recipient age exceeding 60 years and LT results were assessed in multiple Cox regression models.

Results. Recipients older than 60 years (n=107; 13.6%) were characterized by more frequent hepatitis C virus infections (p<0.001), malignancies (p<0.001), and cardiovascular comorbidities (p<0.001); less frequent primary sclerosing cholangitis (p=0.002) and Roux-en-Y hepaticojejunostomy (p<0.001); lower Model for End-stage Liver Disease (MELD; p=0.043); and increased donor age (p=0.012). Fiveyear PS of older and younger recipients was 72.7% and 80.6% (p=0.538), while the corresponding rates of GS were 70.3% and 77.5% (p=0.548), respectively. Recipient age exceeding 60 years was not significantly associated with postoperative mortality (p=0.215), PS (p=0.525) and GS (p=0.572) in multivariate analyses. The list of independent predictors comprised MELD (p<0.001) for postoperative mortality; malignancies (p=0.003) and MELD (p<0.001) for PS; and malignancies (p=0.003), MELD (p<0.001) and donor age (p=0.017) for GS.

Conclusions. Despite major differences between elderly and young patients, chronological age exceeding 60 years alone should not be considered as a contraindication for LT.

Open access

Marek Krawczyk, Piotr Arkuszewski, Krzysztof Zieniewicz and Michał Grąt

Bile Duct Cysts

Aim of the study was analysis of methods of surgical treatment of patients with bile duct cysts.

Material and methods. Retrospective analysis of data from 30 patients who underwent surgical treatment for bile duct cysts in Clinic of General, Transplantation and Liver Surgery, Warsaw Medical University, between 1 October 2001 and 31 December 2009.

Results. Bile duct cysts are more common in females; female to male ration is 4:1. Most of the treated patients had bile duct cysts belonging to type I according to Todani classification — 13 patients (43.3%). Six patients (20%) had type IV cysts, 8 patients (26.7%) had type V cysts according to Todani classification. Three patients (10%) with isolated intrahepatic bile duct cysts were not classified to any group according to Todani classification. The most common type of surgical treatment was complete resection of intrahepatic bile duct with choledocho-intestinal Roux-en-Y anastomosis that was performed in 17 patients (56.7%). The other patients generally underwent various types of resections of the liver and bile ducts or only of the liver. Five patients (16.7%) required liver transplantation. Nine patients (30%) developed complications. One patient (3.3%) who underwent liver transplantation and retransplantation, died from progressive multiorgan failure and renal failure.

Conclusions. First line treatment of patients with bile duct cysts involves their resection, sometimes with requirement of resection of liver parenchyma. Most of these patients underwent reconstruction of bile duct through choledocho-intestinal Roux-en-Y anastomosis. Some patients undergo liver transplantation. Surgical treatment of patients with bile duct cysts is demanding from the technical point of view and should be undertaken in centers that specialize in hepatobiliary surgery.

Open access

Łukasz Masior, Maciej Krasnodębski, Konrad Kobryń, Michał Grąt and Marek Krawczyk

Open access

Wacław Hołówko, Michał Grąt, Barbara Hinderer, Izabela Orlińska and Marek Krawczyk

Abstract

Liver metastases are diagnosed synchronously with the primary tumour in 25% of patients with colorectal cancer. A half of the remaining patients develop liver metastases within 3 years following colectomy. At present, the only radical treatment of metastases is liver resection. Only 2.6% of patients survive 3 years if such treatment is not implemented.

The aim of the study was to assess predictive factors of long-term survival in the group of patients with unresectable colorectal liver metastases carcinoma.

Material and methods. Of 1029 patients with colorectal liver metastases, who were treated in the Department of General, Transplant and Liver Surgery of the Medical University of Warsaw in the years 2006-2012, cases of liver metastases assessed intraoperatively as unresectable were selected. The retrospective analysis included 85 patients. Based on the medical documentation, information concerning age, sex, characteristics of primary and secondary tumours, reasons for unresectability, neoadjuvant chemotherapy as well as local treatment of liver tumours was collected. Preoperative serum concentrations of CEA and CA 19-9 markers were considered. The Cox regression model, Kaplan- Meier estimator and log-rank test were applied in the statistical analyses.

Results. The most common reason for unresectability were: number of metastases in 31 patients (36.5%) and extrahepatic metastases in 19 cases (22.4%). Overall survival in the entire group was 56.1% and 15.5% after 1 and 3 years respectively. A single-factor analysis showed that CEA serum levels (p=0.032; HR=1.002 per increase by 1 ng/ml) and the presence of extrahepatic metastases (p=0.037; HR=2.06) were predictors of worse survival. In a multivariate analysis, CEA concentration (p=0.017; HR=1.002 per increase by 1 ng/ml) was an independent predictor of death whereas the presence of extrahepatic metastases were not statistically significant (p=0.059; HR=2.09).

Conclusions. Serum concentration of CEA marker is an independent predictor of worse survival, but the presence of extrahepatic metastases shows a similar tendency

Open access

Wojciech Figiel, Michał Grąt, Karolina M. Wronka, Waldemar Patkowski, Maciej Krasnodębski, Łukasz Masior, Jan Stypułkowski, Karolina Grąt and Marek Krawczyk

Abstract

Intraabdominal hemorrhage remains one of the most frequent surgical complications after liver transplantation.

The aim of the study was to evaluate risk factors for intraabdominal bleeding requiring reoperation and to assess the relevance of the reoperations with respect to short- and long-term outcomes following liver transplantation.

Material and methods. Data of 603 liver transplantations performed in the Department of General, Transplant and Liver Surgery in the period between January 2011 and September 2014 were analyzed retrospectively. Study end-points comprised: reoperation due to bleeding and death during the first 90 postoperative days and between 90 postoperative day and third post-transplant year.

Results. Reoperations for intraabdominal bleeding were performed after 45 out of 603 (7.5%) transplantations. Low pre-transplant hemoglobin was the only independent predictor of reoperation (p=0.002) with the cut-off of 11.3 g/dl. Postoperative 90-day mortality was significantly higher in patients undergoing reoperation as compared to the remaining patients (15.6% vs 5.6%, p=0.008). Post-transplant survival from 90 days to 3 years was non-significantly lower in patients after reoperation for bleeding (83.3%) as compared to the remaining patients (92.2%, p=0.096). Nevertheless, multivariable analyses did not reveal any significant negative impact of reoperations for bleeding on short-term mortality (p=0.589) and 3-year survival (p=0.079).

Conclusions. Surgical interventions due to postoperative intraabdominal hemorrhage do not appear to affect short- and long-term outcomes following liver transplantation. Preoperative hemoglobin concentration over 11.3 g/dl is associated with decreased risk of this complication, yet the clinical relevance of this phenomenon is doubtful

Open access

Wacław Hołówko, Michał Grąt, Karolina Maria Wronka, Jan Stypułkowski, Rafał Roszkowski, Paweł Studnicki and Marek Krawczyk

Abstract

Liver is the most common location of the colorectal cancer metastases occurrence. Liver resection is the only curative method of treatment. Unfortunately it is feasible only in 25% of patients with colorectal liver metastases, often because of the extensiveness of the disease.

The aim of the study was to evaluate the predictive value of total tumor volume, size and number of colorectal liver metastases in patients treated with right hemihepatectomy.

Material and methods. A retrospective analysis was performed in a group of 135 patients with colorectal liver metastases, who were treated with right hemihepatectomy. Total tumor volume was estimated based on the formula (4/3)πr3. Moreover, the study included an analysis of data on the number and size of tumors, radicality of the resection, time between primary tumor resection and liver resection, pre-operative blood serum concentration of carcinoembryonal antigen (CEA) and carcinoma antigen Ca19-9. The predictive value of the factors was evaluated by applying a Cox proportional hazards model and the area under the ROC curve.

Results. The univariate analysis has shown the predictive value of size of the largest tumor (p=0.033; HR=1.065 per each cm) on the overall survival, however no predictive value of number of tumors (p=0.997; HR=1.000) and total tumor volume (p=0.212; HR=1.002) was observed. The multivariate analysis did not confirm the predictive value of the size of the largest tumor (p=0.141; HR=1.056). In the analysis of ROC curves, AUROC for the total tumor volume, the size of the largest tumor and the number of tumors were 0.629, 0.608, 0.520, respectively.

Conclusions. Total tumor volume, size and number of liver metastases are not independent risk factors for the worse overall survival of patients with colorectal liver metastases treated with liver resection, therefore increased values of these factors should not be a contraindication for surgical treatment

Open access

Marek Krawczyk, Michał Grąt, Oskar Kornasiewicz, Krzysztof Zieniewicz, Paweł Nyckowski, Waldemar Patkowski, Ireneusz Grzelak, Krzysztof Dudek, Tadeusz Wróblewski and Rafał Paluszkiewicz

Liver transplantation in the treatment of patients with hepatocelular carcinoma

The aim of the study was to analyse liver transplantation results in patients with hepatocellular carcinoma, considering selected factors.

Material and methods. The study group comprised 82 patients subject to liver transplantation at the Department of General, Transplant and Liver Surgery, Warsaw Medical University, due to hepatocellular carcinoma. Retrospective analysis concerned the period between 2001 and 2010. Distant survival results were evaluated, depending on whether Milan criteria were fulfilled, and the preoperative level of alpha-fetoprotein estimated. The obtained results were subject to statistical analysis. p<0.05 was considered as statistically significant.

Results. Mean survival time considering patients subject to liver transplantation, due to hepatocellular carcinoma amounted to 66.7 months (95% PU 58.9-74.4), while survival without tumor recurrence - 62.3 months (95% PU 54-70.6). The one, three and five - year survival rate was 88.7%, 74.8% and 72.0%, respectively. Survival without tumor recurrence was 87.5%, 67.1% and 67.1%, respectively. The overall survival of patients fulfilling the Milan criteria (44 of 82 patients - 53.7%) was significantly longer, in comparison to patients not fulfilling the above-mentioned (74.4 and 48.3 months, respectively, p=0.025). A significant difference was also observed, considering the overall survival in the absence of cancer recurrence (72.5 and 42.4 months, respectively, p=0.007). Considering patients not fulfilling the Milan criteria who presented with preoperative alpha-fetoprotein levels > 100 ng/ml, overall survival was shorter, as compared to the mean survival rate: 32.5 and 64.4 months, respectively, p = 0.009. Similar values were obtained in case of patients without tumor recurrence (27 and 57.1 months, p=0.011).

Conclusions. The obtained results confirmed the significant value of Milan criteria, when qualifying patients with hepatocellular carcinoma for liver transplantation. The above-mentioned also showed the potential value of preoperative alpha-fetoprotein level measurements, not only in the diagnostics and early hepatocellular carcinoma diagnosis (patients with cirrhosis), but also in the prediction of survival and tumor recurrence after liver transplantation.

Open access

Marek Krawczyk, Michał Grąt, Karolina Grąt, Karolina Wronka, Maciej Krasnodębski, Jan Stypułkowski, Łukasz Masior, Wacław Hołówko, Joanna Ligocka, Paweł Nyckowski, Tadeusz Wróblewski, Rafał Paluszkiewicz, Waldemar Patkowski, Krzysztof Zieniewicz, Leszek Pączek, Piotr Milkiewicz, Urszula Ołdakowska-Jedynak, Bogusław Najnigier, Krzysztof Dudek, Piotr Remiszewski, Ireneusz Grzelak, Oskar Kornasiewicz, Marcin Kotulski, Piotr Smoter, Mariusz Grodzicki, Michał Korba, Piotr Kalinowski, Michał Skalski, Krzysztof Zając, Rafał Stankiewicz, Marta Przybysz, Bartosz Cieślak, Łukasz Nazarewski, Małgorzata Nowosad, Konrad Kobryń, Michał Wasilewicz, Joanna Raszeja-Wyszomirska, Jolanta Piwowarska, Dorota Giercuszkiewicz, Joanna Sańko-Resmer, Sławomir Rejowski, Monika Szydłowska-Jakimiuk, Barbara Górnicka, Bogna Wróblewska-Ziarkiewicz, Michał Mazurkiewicz, Grzegorz Niewiński, Jacek Pawlak and Ryszard Pacho

Abstract

Liver transplantation is a well-established treatment of patients with end-stage liver disease and selected liver tumors. Remarkable progress has been made over the last years concerning nearly all of its aspects.

The aim of this study was to evaluate the evolution of long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery (Medical University of Warsaw).

Material and methods. Data of 1500 liver transplantations performed between 1989 and 2014 were retrospectively analyzed. Transplantations were divided into 3 groups: group 1 including first 500 operations, group 2 including subsequent 500, and group 3 comprising the most recent 500. Five year overall and graft survival were set as outcome measures.

Results. Increased number of transplantations performed at the site was associated with increased age of the recipients (p<0.001) and donors (p<0.001), increased rate of male recipients (p<0.001), and increased rate of piggyback operations (p<0.001), and decreased MELD (p<0.001), as well as decreased blood (p=0.006) and plasma (p<0.001) transfusions. Overall survival was 71.6% at 5 years in group 1, 74.5% at 5 years in group 2, and 85% at 2.9 years in group 3 (p=0.008). Improvement of overall survival was particularly observed for primary transplantations (p=0.004). Increased graft survival rates did not reach the level of significance (p=0.136).

Conclusions. Long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery are comparable to those achieved in the largest transplant centers worldwide and are continuously improving despite increasing recipient age and wider utilization of organs procured from older donors.

Open access

Marek Krawczyk, Michał Grąt, Krzysztof Barski, Joanna Ligocka, Arkadiusz Antczak, Oskar Kornasiewicz, Michał Skalski, Waldemar Patkowski, Paweł Nyckowski, Krzysztof Zieniewicz, Ireneusz Grzelak, Jacek Pawlak, Abdulsalam Alsharabi, Tadeusz Wróblewski, Rafał Paluszkiewicz, Bogusław Najnigier, Krzysztof Dudek, Piotr Remiszewski, Piotr Smoter, Mariusz Grodzicki, Michał Korba, Marcin Kotulski, Bartosz Cieślak, Piotr Kalinowski, Piotr Gierej, Mariusz Frączek, Łukasz Rdzanek, Rafał Stankiewicz, Konrad Kobryń, Łukasz Nazarewski, Dorota Leonowicz, Magdalena Urban-Lechowicz, Anna Skwarek, Dorota Giercuszkiewicz, Agata Paczkowska, Jolanta Piwowarska, Remigiusz Gelo, Paweł Andruszkiewicz, Anna Brudkowska, Renata Andrzejewska, Grzegorz Niewiński, Beata Kilińska, Aleksandra Zarzycka, Robert Nowak, Cezary Kosiński, Teresa Korta, Urszula Ołdakowska-Jedynak, Joanna Sańko-Resmer, Bartosz Foroncewicz, Jacek Ziółkowski, Krzysztof Mucha, Grzegorz Senatorski, Leszek Pączek, Andrzej Habior, Robert Lechowicz, Sławomir Polański, Elżbieta Leowska, Ryszard Pacho, Małgorzata Andrzejewska, Olgierd Rowiński, Sławomir Kozieł, Jerzy Żurakowski, Bogna Ziarkiewicz-Wróblewska, Barbara Górnicka, Piotr Hevelke, Bogdan Michałowicz, Andrzej Karwowski and Jerzy Szczerbań

1000 Liver Transplantations at the Department of General, Transplant and Liver Surgery, Medical University of Warsaw - Analysis of Indications and Results

The aim of the study was to analyze indications and results of the first one thousand liver transplantations at Chair and Clinic of General, Transplantation and Liver Surgery, Medical University of Warsaw.

Material and methods. Data from 1000 transplantations (944 patients) performed at Chair and Clinic of General, Transplantation and Liver Surgery between 1994 and 2011 were analyzed retrospectively. These included 943 first transplantations and 55 retransplantations and 2 re-retransplantations. Frequency of particular indications for first transplantation and retransplantations was established. Perioperative mortality was defined as death within 30 days after the transplantation. Kaplan-Meier survival analysis was used to estimate 5-year patient and graft survival.

Results. The most common indications for first transplantation included: liver failure caused by hepatitis C infection (27.8%) and hepatitis B infection (18%) and alcoholic liver disease (17.7%). Early (< 6 months) and late (> 6 months) retransplantations were dominated by hepatic artery thrombosis (54.3%) and recurrence of the underlying disease (45%). Perioperative mortality rate was 8.9% for first transplantations and 34.5% for retransplantations. Five-year patient and graft survival rate was 74.3% and 71%, respectively, after first transplantations and 54.7% and 52.9%, respectively, after retransplantations.

Conclusions. Development of liver transplantation program provided more than 1000 transplantations and excellent long-term results. Liver failure caused by hepatitis C and B infections remains the most common cause of liver transplantation and structure of other indications is consistent with European data.