[Show abstract][Hide abstract] ABSTRACT: There is controversy concerning the effect of a positive T-lymphocytotoxic crossmatch (TLC) on clinical outcomes in adult living donor liver transplantation (LDLT). The aim of this study was to investigate the effect of TLC on clinical outcomes in LDLT and to determine how long a pretransplant positive TLC continues after liver transplantation (LT).
Between January 2005 and June 2010, 219 patients underwent adult LDLT at National Cancer Center. The TLC test was routinely performed before LDLT. TLC test results were positive in 8 patients (3.7%). Patients were divided into 2 groups according to the result of TLC: positive TLC (n = 8) and negative TLC (n = 211) groups. All patients with a pretransplant positive TLC (n = 6) underwent a TLC test every week until negative conversion of TLC, except 2 patients who refused to receive the TLC test.
Acute cellular rejection, surgical complications and patient or graft survival were not significantly different between both groups. All patients with a positive TLC (n = 6) had a posttransplant negative TLC. The median time to negative conversion of TLC was 1.5 weeks (range, 1 to 3 weeks).
A pretransplant positive TLC does not affect clinical outcomes in adult LDLT. Moreover, T-lymphocytotoxic cross-reactivity disappeared within 3 weeks (range, 1 to 3 weeks) after LT.
Journal of the Korean Surgical Society 04/2013; 84(4):245-51. · 0.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Steroid use after liver transplantation is known to increase the risk of new-onset diabetes mellitus (NODM). In this study, we tried to identify a patient subgroup who would benefit with regard to NODM by an early steroid withdrawal regimen (ESWR) after living donor liver transplantation (LDLT) METHODS: Among 100 adult LDLT patients, 65 were on a conventional immunosuppressive regimen (CIR), and 35 were on an ESWR. With the ESWR, the steroid was tapered off mostly within 7 days with induction of basiliximab in combination with tacrolimus and mycophenolate mofetil (MMF). The CIR was a combination of tacrolimus and steroid. MMF was added in selected patients. Steroid was tapered off 2-6 months after LT. The presence of NODM was investigated cross-sectionally 6 months after LT.
There was no significant difference in terms of acute cellular rejection, sepsis, or death during follow-up. NODM had developed in 13 patients (13 %). Old recipient age (≥55) and pretransplant history of hypertension were significant risk factors for NODM. The type of immunosuppression was the single risk factor for NODM in subgroup of old-age recipients (≥55 years) on the CIR (hazard ratio 13.34, p = 0.04).
ESWR can safely reduce the incidence of NODM after LDLT in old-age recipients. Therefore, ESWR should be considered first in old-age recipients undergoing LDLT.
World Journal of Surgery 06/2012; 36(10):2443-8. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine the significance of portal vein-superior mesenteric vein (PV-SMV) invasion on survival in patients who underwent margin-negative pancreatoduodenectomy (PD) with PV-SMV resection for pancreatic adenocarcinoma.
We retrospectively reviewed the records of 60 patients who underwent margin-negative PD with or without PV-SMV resection for pancreatic adenocarcinoma between August 2001 and December 2007. The depth of vessel invasion was investigated and was categorized into 3 groups: tunica adventitia, media, and intima. Clinicopathologic factors and survival were analyzed.
Portal vein-superior mesenteric vein resection was performed on 19 patients, but only 15 patients (78.9%) had histologically true invasion and showed poorer survival (median survival, 14 vs 9 months; P < 0.05). Univariate analysis revealed that poorly differentiated tumor, lymphatic invasion, endovascular invasion, PV-SMV invasion, and invasion into the intima of PV-SMV were statistically significant. Poorly differentiated tumor and invasion into the intima of PV-SMV were significant in multivariate analysis.
Aggressive surgical resection should be attempted in cases with suspected PV-SMV invasion because 21.1% of patients had no true invasion and showed better survival than those with true invasion. However, invasion into the tunica intima may be a poor prognostic factor for survival even after margin-negative PD for pancreatic adenocarcinoma.
[Show abstract][Hide abstract] ABSTRACT: Over a period of 2 years, we used an upper midline incision (UMI) without laparoscopic assistance in 143 consecutive living donor partial hepatectomy (LDPH) procedures, regardless of the graft type or the donor age, sex, body mass index, or body shape. Here we report surgical recommendations based on our experience with the use of UMIs in this context. The celiac axis (CA) depth ratio (the depth-to-width ratio for the trunk at the CA) was measured to define the shape of the abdominal cavity. A questionnaire was used to assess satisfaction and cosmetic outcomes in this population of donors. One hundred forty-one of the grafts (98.6%) were right grafts or extended right grafts; there were no donor deaths. The mean time of the operation up to graft retrieval in 141 right side grafts was 3 hours 1 minute. All donors recovered fully and returned to their previous activities. Major complications occurred in 9 patients (6.4%) and included reoperation due to bleeding (4), the insertion of a percutaneous drain (4), and rhabdomyolysis (1). Male sex, a large graft (>900 kg), a fatty liver (large fatty changes ≥ 10%), and a deep truncal cavity (a CA depth ratio > 0.35) were significant risk factors for a long graft retrieval time. The use of a wound protector significantly reduced wound complications. The cosmetic outcomes were more satisfactory when a UMI preceded partial hepatectomy instead of a conventional J-shaped incision (P = 0.01). In conclusion, a UMI without laparoscopic assistance can be safely used for LDPH, regardless of the graft type or the donor characteristics. However, the procedure after a UMI is more difficult in male donors with large fatty livers and deep truncal cavities. Accordingly, these features can be used as exclusion criteria for surgeons not accustomed to this modified procedure.
[Show abstract][Hide abstract] ABSTRACT: Duct-to-duct reconstruction (DDR) of the bile duct has recently become the preferred choice in living donor liver transplantation (LDLT), but biliary complications still remain the most common cause of morbidity. We introduce our new technique of tailored telescopic reconstruction (TTR) of the bile duct for reducing bile duct complications in LDLT: the hilar plate covering the right and left hepatic ducts is bisected lengthwise through the right or left hepatic duct opening to make a funnel-shaped top, into which the donor hepatic duct is telescoped to match the recipient bile duct in size, and DDR is performed in the inner tissue of good vascular integrity of the recipient bile duct without redundancy. Forty-five consecutive LDLT procedures from January to August 2008 were analyzed through a comparison of 23 conventional duct-to-duct reconstructions (cDDRs) and 22 TTRs in bile duct anastomoses. At a mean follow-up of 19.5 months, the rates of overall biliary complications, leakage, and strictures were 43.5%, 26.1%, and 34.8%, respectively, for cDDR and 9.1%, 0%, and 9.1%, respectively, for TTR (P < 0.05 for each). In conclusion, TTR of the bile duct results in excellent outcomes with respect to minimization of biliary complications; thus, TTR can be recommended as a preferred method for biliary reconstruction in LDLT.
[Show abstract][Hide abstract] ABSTRACT: Gallbladder cancer is a relatively uncommon gastrointestinal malignancy. Indications for adjuvant chemoradiation therapy after surgical resection have not yet been determined. We aimed this study to elucidate the effectiveness of adjuvant chemoradiation therapy according to TNM stage for gallbladder cancer.
Between March 2001 and March 2009, 100 patients with gallbladder cancer underwent surgical resection. We divided the patients according to TNM stage, and subdivided further according to whether adjuvant chemoradiation therapy was added or not. The clinicopathologic factors, recurrence and survival were retrospectively analyzed.
Patients with gallbladder cancer at T2N0M0, T2N1M0, T3N0M0, and T3N1M0 stages were enrolled in this study. Among the four stages, the two lymph node-negative stages (T2N0M0 and T3N0M0) did not show any gain in survival by adding adjuvant chemoradiation therapy. Conversely, the remaining lymph node-positive stages (T2N1M0 and T3N1M0) showed gain in disease-free survival, and the lymph node-positive T2 stage (T2N1M0) showed gain in disease-specific survival. In patients with lymph node-positive T2/T3 GB cancers, adjuvant chemoradiation therapy was an independent prognostic factor for survival.
Adjuvant chemoradiation therapy is recommended for lymph node-positive T2/T3 gallbladder cancer following surgical resection.
Journal of Surgical Oncology 07/2010; 102(1):87-93. · 2.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: (18)F-fluoro-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography (PET)/computed tomography (CT) has recently been shown to be able to predict a poor outcome after liver transplantation (LT) for patients with hepatocellular carcinoma (HCC). However, there are few reports on the usefulness of PET during follow-up after LT. In this study, we assessed the efficacy of (18)F-FDG PET/CT for the detection of HCC recurrence after LT. From February 2005 to December 2008, out of 93 adult LT cases (91 living donors and 2 deceased donors), 10 patients who showed HCC recurrence and received (18)F-FDG PET/CT during follow-up were included. The accuracy of (18)F-FDG PET/CT was assessed with imaging and histological studies. The most common sites of recurrence were extrahepatic (60%). The most common extrahepatic sites were the lungs and bone (31.3% each). Among 4 patients with intrahepatic recurrence, 1 patient (25%) was positive according to (18)F-FDG PET/CT. The detection rate of (18)F-FDG PET/CT was 92.9% for extrahepatic metastases >or= 1 cm and 0% for lesions < 1 cm. The detection rate of (18)F-FDG PET/CT was 100% in bone and the lymph nodes, 60% in the lungs, and 0% in the brain. (18)F-FDG PET/CT identified 2 lesions in bone that were not found in a bone scan. In conclusion, because of its limitations for small lesions, intrahepatic lesions, and brain lesions, (18)F-FDG PET/CT is not suitable as a screening tool after LT. However, (18)F-FDG PET/CT could provide additional information beyond that provided by conventional modalities, and it could contribute to the clinical management of HCC recurrence after LT, especially in patients with extrahepatic recurrence.
[Show abstract][Hide abstract] ABSTRACT: Gallbladder (GB) cancer may be discovered incidentally by histopathologic examination following simple cholecystectomy. Incidental GB cancer > or =T2 or > or =N1 needs a second radical resection. It is a matter of concern whether the prognosis may be worse in patients with T2GB cancer who undergo a second radical resection than in those who undergo primary radical resection.
Between March 2001 and March 2009, 21 patients underwent a one-step operation (OSO group), and 17 patients underwent a two-step operation (TSO group) for T2GB cancer. We compared clinicopathologic factors and survival between patients in the OSO group (n = 9) and those in the TSO group (n = 9) with T2N0M0 GB cancer and between patients in the OSO group (n = 12) and those in the TSO group (n = 8) with T2N1M0 GB cancer.
Except for patient age, clinicopathologic factors as well as disease-free survival were not significantly different between the OSO group and the TSO group in the aforementioned cancer stages. Patient age was significantly higher in the OSO group than in the TSO group.
Second completion radical resection following initial simple cholecystectomy (TSO) provided a survival benefit similar to that of primary radical surgery (OSO) for patients with both T2N0M0 and T2N1M0 GB cancers in our study.
World Journal of Surgery 03/2010; 34(7):1572-8. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy, but the studies for the outcome after resection of ICC are rare. The aim of this study was to elucidate outcomes and prognostic factors of ICC in patients undergoing hepatic resection.
A retrospective study was conducted with a total of 63 patients who underwent surgical resection with curative intent for ICC. We performed the survival analysis with preoperative and postoperative clinicopathologic factors according to the clinical outcome.
The cumulative 1-, 3-, and 5-year survival rates were 68.2, 50.5, and 31.8%, respectively. Univariate analysis revealed that patient's old age, high preoperative carbohydrate antigen 19-9 (CA19-9) level, major vessel invasion, T classification, lymph node metastasis, lymphatic invasion, perineural invasion, intrahepatic metastasis, and narrow resection margin were statistically significant. By multivariate analysis, patient's old age, high preoperative CA19-9 level, lymphatic invasion, and narrow resection margin were independent dismal prognostic factors. The preoperative CA19-9 level shows a significant correlation with some histopathologic factors including major vessel invasion, bile duct invasion, and perineural invasion.
Preoperative CA19-9 level was a valuable clinical factor for predicting histopathologic invasiveness as well as clinical outcome. An adequate resection margin was the only modifiable factor by a surgeon during hepatic resection for ICC.
Annals of Surgical Oncology 02/2010; 17(7):1823-30. · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hepatocellular carcinoma (HCC) has become one of the main indications for liver transplantation. To keep abreast of the times, a comprehensive cancer center may have to perform liver transplantation as a treatment option for HCC. We introduce a learning curve for living-donor liver transplantation(LDLT) and present our initial experience in a new cancer center as an example to any center considering LDLT. A total of 51 consecutive adult right liver LDLTs performed from January 2005 to January 2008 were analyzed by comparing the first 17 transplants performed with the help of an outside experienced team (group 1) with the middle 17 (group 2) and the last 17 cases(group 3) performed in our center independently. There was no hospital mortality in donors and recipients. In a mean follow-up of 34 months (range: 12-48 months), there was only one case of late mortality in donor and recipient,respectively. A total of four donors and 12 recipients underwent re-operations.The warm ischemic time was significantly longer in group 2 than that in groups 1 and 3. Otherwise, there was no significant difference in the operative outcomes among the three groups. Thorough preparation and the assistance of an experienced liver transplantation team at the beginning can facilitate a more rapid learning curve and bring about a good outcome even in a small, newly established institution.
Transplant International 12/2009; 22(12):1164-71. · 3.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Innovations and refinements in the techniques of living donor right hepatectomy (LDRH) have been made over the past decades, but the type and size of abdominal incision have been at a standstill since its inception. We introduce herein the upper midline incision for LDRH using the standard open technique. A prospective case-matched study was conducted on 23 consecutive donors who underwent LDRH under a supraumbilical upper midline incision (I group) from February to May 2008. These donors were matched 1:1 to 23 right liver donors with a conventional J-shaped incision (J group) according to age, gender, and body mass index. Under the mean incision length of 13.5 cm, LDRH was successfully completed in all 23 donors without extension of the incision, with a mean operative time of 232.3 +/- 29.2 minutes. No donors required blood transfusion during surgery. There were 2 cases of postoperative bleeding immediately controlled under the same incision and a case of pleural effusion. All donors fully recovered and returned to their previous activities. All grafts have been functioning well. Compared with the J group, the I group had a shorter operative time, a shorter period of analgesic use, and, after discharge, infrequent complaints of wound pain. This upper midline incision, even without laparoscopic assistance, can be used for LDRH with less pain and without impairing safety, reproducibility, or effectivity, allowing the seemingly insufficient incision to be recommended to the transplant centers that are practicing living donor liver transplantation.