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ABSTRACT: This study aimed to analyze the clinical outcomes and factors influencing the outcome in the recurrence of hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT). Between October, 1997 and September, 2010, 25 (16.0%) of 156 patients who had undergone LDLT for HCC experienced recurrence. All patients with recurrence, with a single exception, were in the high-risk group. Among patients with recurrence, 76.0% of patients experienced recurrence within one yr after LDLT. One- and five-yr survival rates of recurred patients were 56.0% and 8.6%, respectively. Among them, 32% of patients were treated with curative-intent treatment, and their one- and five-yr survival rates were 62.5% and 25.0%, respectively. Beyond the Milan criteria at liver transplantation (LT) (p = 0.032), multiple recurrence (p = 0.001), and palliative treatment for recurrent tumors (p = 0.049) were related to poor survival after recurrence. Additionally, the independent prognostic factors included multiple recurrence (p = 0.005) and the Milan criteria at LT (p = 0.047). Because almost all recurrent cases belonged to the high-risk group and recurred within two yr, the high-risk group should undergo close follow-up for early detection and be treated with liver-directed therapies. Although the prognosis of recurrent HCC after LDLT is poor, long-term survival can be expected on a single recurrence and curative treatment.
Clinical Transplantation 02/2013; · 1.67 Impact Factor
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ABSTRACT: To investigate the usefulness of a new rendezvous technique for placing stents using the Kumpe (KMP) catheter in angulated or twisted biliary strictures.
The rendezvous technique was performed in patients with a biliary stricture after living donor liver transplantation (LDLT) who required the exchange of percutaneous transhepatic biliary drainage catheters for inside stents. The rendezvous technique was performed using a guidewire in 19 patients (guidewire group) and using a KMP catheter in another 19 (KMP catheter group). We compared the two groups retrospectively.
The baseline characteristics did not differ between the groups. The success rate for placing inside stents was 100% in both groups. A KMP catheter was easier to manipulate than a guidewire. The mean procedure time in the KMP catheter group (1012 s, range: 301-2006 s) was shorter than that in the guidewire group (2037 s, range: 251-6758 s, P = 0.022). The cumulative probabilities corresponding to the procedure time of the two groups were significantly different (P = 0.008). The factors related to procedure time were the rendezvous technique method, the number of inside stents, the operator, and balloon dilation of the stricture (P < 0.05). In a multivariate analysis, the rendezvous technique method was the only significant factor related to procedure time (P = 0.010). The procedural complications observed included one case of mild acute pancreatitis and one case of acute cholangitis in the guidewire group, and two cases of mild acute pancreatitis in the KMP catheter group.
The rendezvous technique involving use of the KMP catheter was a fast and safe method for placing inside stents in patients with LDLT biliary stricture that represents a viable alternative to the guidewire rendezvous technique.
World Journal of Gastroenterology 11/2012; 18(41):5957-64. · 2.47 Impact Factor
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ABSTRACT: Liver transplantation (LT) is a curative modality for hepatocellular carcinoma (HCC) especially in patients with cirrhosis. However, there are still risks of recurrences. C-reactive protein (CRP), an acute-phase inflammatory reactant which is synthesized by hepatocytes, has been related to prognosis in various malignancies, including HCC. In this study, we investigated a role of high CRP level in predicting post-transplant outcomes of HCC. From August 2000 to July 2010, 85 patients who had available pre-transplant serum CRP levels were analyzed. Only 2 patients received diseased donor LT, and the remaining patients received living donor LT. Using 1 mg/dL as a cut-off value, 27 patients showed high CRP levels (ó1 mg/dL), and 58 showed low CRP levels (<1 mg/dL) when received LT. Total bilirubin, Child-Pugh grade, model for end-stage liver disease score, maximal tumor size and the frequency of intrahepatic metastasis were significantly higher in the high CRP group. In multivariate analyses, HCC over the Milan criteria, high CRP level and microvascular invasion were related to tumor recurrence, and high CRP level and microvascular invasion were related to poor overall survival. When subgroup analysis was done according to the Milan criteria, the high CRP level was an independent factor to predict poor outcomes in patients with HCC over the Milan criteria (P = 0.015 for recurrence, P <0.001 for survival), while not for patients under the criteria. Serum CRP would be considered as a useful and cost-effective biomarker to predict outcomes after LT for HCC, particularly in patients over the Milan criteria. © 2012 American Association for the Study of Liver Diseases.
Liver Transplantation 07/2012; · 3.39 Impact Factor
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ABSTRACT: We retrospectively compared the efficacy and toxicity of gemcitabine combination with capecitabine or erlotinib in unresectable pancreatic cancer to know whether the combination with cytotoxic and target agent has more benefit comparing to combination of cytotoxic agents.
Fifty-three patients with unresectable pancreatic cancer, treated with gemcitabine and capecitabine (GC) or gemcitabine and erlotinib (GE) as first line between October 2006 and July 2010, were reviewed. In GC group, patients were treated with gemcitabine 1,000 mg/m(2) on days 1, 8, and capecitabine 1,300 mg/m(2) bid was administered on days 1-14, repeated every 21 days. In GE group, gemcitabine was given at 1,000 mg/m(2) I.V for 30 min on days 1,8,15, and erlotinib was taken orally at 100 mg through days 1-28, repeated every 28 days.
Response rate was similar, 23.5 % in GE and 21.1 % in GC, but GC had better disease control rate with 73.7 % than GE with 52.9 %. GC also showed longer PFS and OS (5.37 and 14.43 months) than GE (2.63 and 6.23 months) (p = 0.032 for PFS and 0.002 for OS). In toxicity profiles, GC had more hematologic toxicities and GE had more non-hematologic toxicities.
The combination with cytotoxic agents seems to have better efficacy and clinical outcome than combination with cytotoxic agent and target agent. The new combination should be developed for the treatment for advanced pancreatic cancer.
Journal of Cancer Research and Clinical Oncology 05/2012; 138(10):1625-30. · 2.56 Impact Factor
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ABSTRACT: Single-port laparoscopic surgery is slowly but steadily gaining popularity among surgeons performing minimally invasive abdominal surgeries. The aim of the present study is to assess our initial experience with single-port laparoscopic liver resection for hepatocellular carcinoma.
Between March 2009 and April 2011, 24 patients underwent single-port laparoscopic liver resection for hepatocellular carcinoma. Of these, 13 were laparoscopic segmentectomies, 4 were laparoscopic left lateral sectionectomies, 1 was a right hepatectomy, 1 was a left hepatectomy, and 4 were nonanatomical resections.
Median operating time and blood loss were 205 min (95-545 min) and 500 ml (100-2,500 ml), respectively. Two procedures were converted to multiport laparoscopic hepatectomy due to instrument length limitations, and four were converted to open surgery. There were no serious intraoperative or postoperative complications in this series. Median postoperative stay was 8.5 days (5-16 days).
Although the procedure requires a lot of technical expertise added to the skill of liver surgery, single-port laparoscopic liver resection for hepatocellular carcinoma seems a feasible approach in a variety of well-selected cases. In spite of the demanding nature of the procedure and the requirement of better instrumentation for single-port laparoscopic surgery, the results seem to compare favorably with conventional laparoscopic surgery and open surgery.
Surgical Endoscopy 12/2011; 26(6):1602-8. · 4.01 Impact Factor
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ABSTRACT: The aim of this report was to describe a new reconstructive technique of pancreaticogastrostomy and to also discuss this procedure's effectiveness for reducing the incidence of postoperative complications.
We retrospectively analyzed early surgical outcomes in 21 consecutive patients who underwent this novel pancreaticogastrostomy after pancreaticoduodenectomy. Pancreaticogastrostomy was completed with 2 transpancreatic sutures with buttresses on both the upper and lower edges of the implanted pancreas through the retracted anterior gastrotomy.
Operative mortality was zero and morbidity was 23.8%. A significant pancreatic fistula occurred in 1 patient (4.7%; grade B).
This technique is very easy to perform, less traumatic to the pancreatic stump, can be performed through a mini-laparotomy due to good vision and straight sutures, and it is secure owing to anchoring of the invaginated pancreatic stump to the stomach's posterior wall with buttresses. The results of this pilot study indicate that the technique may provide a favorable outcome and could be an alternative method of pancreatoenteric anastomosis. However, to determine its superiority over the conventional procedures, this operative technique should be evaluated more comprehensively in a larger series.
Journal of the Korean Surgical Society. 11/2011; 81(5):332-8.
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ABSTRACT: With the better understanding of the importance of the spleen as a primary organ of the human immune system, there has been an increased interest in performing the partial splenectomy for a number of indications such as nonparasitic cysts, benign tumors, staging of lymphomas, etc. Moreover, laparoscopic partial splenectomy has been gaining more interest as the recommended approach for benign splenic disorders to preserve the splenic function with very low recurrence rates. Meanwhile, many surgeons have attempted to reduce the number and size of the ports in laparoscopic surgery with the aim of inducing less parietal trauma and fewer scars. One of these efforts is single-port laparoscopic surgery, which is a rapidly evolving field all over the world. Here, we describe a feasible method of single-port laparoscopic partial splenectomy for treating a benign splenic cyst that was located in the upper medial aspect of the spleen.
Surgical laparoscopy, endoscopy & percutaneous techniques 10/2010; 20(5):e164-6. · 1.23 Impact Factor
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ABSTRACT: Biliary stricture is the most common and important complication after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary anastomosis. This study evaluated the efficacy and long-term outcome of endoscopic treatment for biliary stricture after LDLT, with the aim of identifying the factors that influence the outcome.
Three hundred and thirty-nine adults received RL-LDLTs with duct-to-duct biliary anastomosis between January 2000 and May 2008 at Kangnam St. Mary's Hospital. Endoscopic retrograde cholangiography (ERC) was performed in 113 patients who had biliary stricture after LDLT. We evaluated the incidence of post-LDLT biliary stricture and the long-term outcome of endoscopic treatment for biliary stricture. The factors related to the outcome were analyzed.
Biliary strictures developed in 121 (35.7%) patients, 95 (78.5%) of them within 1 year of surgery. The mean number of ERCs performed per patient was 3.2 (range, 1 to 11). The serum biochemical markers decreased significantly after ERC (p<0.001). Stent insertion or stricture dilatation during ERC was successful in 90 (79.6%) patients. After a median follow-up period of 33 months from the first successful treatment with ERC, 48 (42.5%) patients achieved treatment success and 12 (10.6%) patients remained under treatment. The factors related to the outcome of endoscopic treatment were nonanastomotic stricture and stenosis of the hepatic artery (p=0.016).
Endoscopic treatment is efficacious and has an acceptable long-term outcome in the management of biliary strictures related to RL-LDLT with duct-to-duct biliary anastomosis. Nonanastomotic stricture and stenosis of the hepatic artery are correlated with a worse outcome of endoscopic treatment.
Gut and liver 06/2010; 4(2):226-33. · 0.83 Impact Factor
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ABSTRACT: According to recent prevalence of hepatitis A virus (HAV) infection, acute liver failure (ALF) due to HAV infection is observed frequently in parallel. The aim of this study was to elucidate the clinical, laboratory, and pathologic features of patients who have undergone emergency liver transplantation (LT) due to fulminant HAV infection.
Clinical, laboratory, and pathologic data of 11 transplant recipients with anti-HAV IgM-positive ALF between December 2007 and May 2009 were analyzed, and compared with data of 10 recipients who underwent LT for the management of ALF due to other causes.
The median age of the patients with HAV-related ALF was 34 years (range: 15-43 years). The levels of hemoglobin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatinine were higher and the level of bilirubin was lower in the HAV-related ALF group than in the other group (P=0.005, 0.001, 0.001, 0.010, and 0.003, respectively). The time from the onset of initial symptoms to the development of encephalopathy was shorter in the HAV-related ALF group than in the other group (median 5 days, range: 4-13 days; P<0.001). In patients with HAV-related ALF, laboratory findings and clinical prognostic parameters including the Acute Liver Failure Study Group prognostic index, King's College criteria, and model for endstage liver disease (MELD) and Child-Pugh scores were not associated with the grade of hepatic encephalopathy or time of progression to encephalopathy.
The results of this study indicate that the clinical condition of patients with HAV-related ALF requiring emergency LT aggravates rapidly. Prognostic parameters are not sufficient for discriminating transplant candidates in patients with fulminant hepatitis A.
The Korean Journal of Hepatology 03/2010; 16(1):19-28.
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ABSTRACT: Replacement of a percutaneous transhepatic biliary drainage (PTBD) catheter with inside stents using endoscopic retrograde cholangiography is difficult in patients with angulated or twisted biliary anastomotic stricture after living donor liver transplantation (LDLT). We evaluated the usefulness and safety of the rendezvous technique for the management of biliary stricture after LDLT.
Twenty patients with PTBD because of biliary stricture after LDLT with duct-to-duct anastomosis underwent the placement of inside stents using the rendezvous technique.
Inside stents were successfully placed in the 20 patients using the rendezvous technique. The median procedure time was 29.6 (range, 7.5-71.8) minutes. The number of inside stents placed was one in 12 patients and two in eight patients. One mild acute pancreatitis and one acute cholangitis occurred, which improved within a few days. Inside stent related sludge or stone was identified in 12 patients during follow-up. Thirteen patients achieved stent-free status for a median of 281 (range, 70-1,351) days after removal of the inside stents.
The rendezvous technique is a useful and safe method for the replacement of PTBD catheter with inside stent in patients with biliary stricture after LDLT with duct-to-duct anastomosis. The rendezvous technique could be recommended to patients with angulated or twisted strictures.
Gut and liver 03/2010; 4(1):68-75. · 0.83 Impact Factor
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ABSTRACT: Since the introduction of laparoscopic surgery, surgeons have not only been concerned about clinical outcomes, but also surgical scars. Although natural orifice transluminal endoscopic surgery (NOTES) is promising, it is not applicable to clinical practice thus far due to safety concerns. As a transitional procedure between standard laparoscopic surgery and NOTES, single-port transumbilical laparoscopic surgery might be an ideal alternative. The main advantage of single-port transumbilical laparoscopic surgery is that it is performed with existing instruments. Thus, we applied single-port surgery for cholecystectomies and the clinical outcomes were analyzed.
Between July and October 2008, 37 adults with gallbladder pathologies were enrolled in this study. Only one transumbilical incision was made for accessing the abdominal cavity and a multichannel port system was assembled with existing devices. Standard laparoscopic instruments were used to perform the cholecystectomy.
There were 13 males and 24 females. The mean age of the patients was 47.5 +/- 12.2 years. Twenty-nine patients had gallbladder stones, 7 patients had gallbladder polyps, and 1 patient had biliary dyskinesia. The mean operative time was 83.6 +/- 40.2 minutes. Gallbladder perforations occurred in 11 patients. In 5 patients, the procedure was converted to a standard laparoscopic technique due to technical difficulties. Complications occurred in 2 patients; specifically, a mesenteric injury was caused by the inadvertent grasping of the small-bowel mesentery during the removal of the wound retractor and an inadvertent injury of the right hepatic duct. The mean hospital stay was 2.7 +/- 1.5 days.
Our series has demonstrated the feasibility and safety of single-port transumbilical laparoscopic cholecystectomy. When technical difficulties arise, early conversion to a standard laparoscopic technique is advised to avoid serious complications. Additional studies randomizing standard laparoscopic cholecystectomy and single-port transumbilical cholecystectomy are necessary for defining the exact role of this procedure.
Journal of Laparoendoscopic & Advanced Surgical Techniques 08/2009; 19(4):495-9. · 1.40 Impact Factor
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ABSTRACT: Laparoscopic appendectomy is generally performed with the three-port system. In this study, we performed a unique single-port laparoscopic appendectomy, which we refer to as the transumbilical single-port laparoscopic appendectomy (TUSPLA).
From April 19, 2008, 33 cases of TUSPLA were performed. A surgical glove was used as the "single-port" with an extra-small wound retractor, which was set up through a small umbilical incision. The surgical glove attached with one trocar and two pipes were then fixed to the outer ring of the wound retractor, which served as a single port with three working channels. Using this single-port system, TUSPLA was performed. The overall procedure was similar to that used for the three-port laparoscopic appendectomy.
TUSPLA was attempted in 33 patients (11 males and 22 females), with an average age of 31.2 years (range, 14-73). Average patient body mass index was 22.8 kg/m2 (range, 16.8-35.8). TUSPLA was successfully completed in 31 patients. In 2 cases, the operation was converted to the conventional three-port laparoscopic appendectomy due to a gangrenous change at the base of the appendix in 1 case and the need for drainage in another. Mean operation time was 40.8 minutes (range, 15-90), and mean postoperative hospital stay was 2.5 days (range, 1-11). Postoperative complications occurred in 3 cases; 2 cases were of localized pericecal abscess and 1 case was of omphalitis, and all were treated conservatively.
TUSPLA is a safe, effective technique that allows nearly scarless abdominal surgery.
Journal of Laparoendoscopic & Advanced Surgical Techniques 02/2009; 19(1):75-8. · 1.40 Impact Factor
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ABSTRACT: A lipoma of the diaphragm is extremely rare. Although most congenital diaphragmatic lipomas are encountered in middle or old age because of their typical asymptomatic nature, none have been reported in patients younger than 14 years. We report the case of a large diaphragmatic lipoma in a 4-year-old patient.
Journal of Pediatric Surgery 02/2006; 41(1):e37-9. · 1.45 Impact Factor
