Eung Chang Lee

Survival Analysis after Liver Resection for Hepatocellular Carcinoma: A Consecutive Cohort of 1002 Patients.

The improvements in surgical technique and perioperative management in the recent decades may warrant revisit for survival outcomes and prognostic factors after liver resection for hepatocellular carcinoma (HCC). This study aimed to analyze the survival outcomes after liver resection for HCC for a consecutive cohort of 1002 patients.

The Impact of a Surgical Protocol for Enhanced Recovery on Living Donor Right Hepatectomy: A Single-Center Cohort Study.

AbstractThe concept of surgery for enhanced recovery (SFER) program has never been an issue in the context of living donor right hepatectomy (LDRH), much less its effects. The purpose of this study was to evaluate outcomes after the establishment of an SFER protocol for LDRH in a single center.A single-center cohort study was performed in 500 consecutive living donors who underwent right hepatectomy from January 2005 to June 2014 by analyzing the outcomes before and after an established SFER protocol that evolved with continuous refinements in surgical technique and management over 300 LDRHs, being in place on September 2011. Donor characteristics, operative outcomes, and postoperative complications divided into 2 groups (group 1, stepwise adjustment; group 2, complete adherence to the protocol) were compared.Donor characteristics were comparable in the 2 groups. Overall complication rate was 10.0% with no mortality. In group 2, operative time, hospital stay, and overall complication rate decreased significantly, and the morbidity was 1% and confined in grade I complication without reoperation, perioperative blood transfusion, or readmission. All donors in this series recovered fully and returned to the previous functional lifestyle.An SFER protocol on LDRH can be established by the gradual implementation of various refinements of surgical technique, and the recent outcomes achieved after the establishment of an SFER protocol could provide a current guidance on LDRH toward the ultimate goal of zero morbidity.

Ligation and cut as a method for bile duct division in living donor right hepatectomy

The importance of bile duct division cannot be overemphasized in living donor surgery. Ligation and cut (LC) as a method for bile duct division in living donor right hepatectomy (LDRH) has never been reported. The purpose of this study was to introduce the LC method of bile duct division in LDRH. All LDRH donors were identified through a prospectively maintained database at the authors’ institution between September 2009 and March 2013, and the 2 methods, LC and cut and oversewing (CO), were compared both in terms of donor and recipient outcomes of right lobe living donor liver transplantation. In the LC method, after complete parenchymal transection, the right hepatic duct was dissected in the Glissons sheath and ligated just at the right side of the confluence, and then the right side of the ligature was cut. The LC and CO methods were performed in 109 and 134 donors, respectively. Bile duct division time (P < 0.001) and operative time (P < 0.001) were significantly shorter in the LC group than in the CO group. With a median follow‐up of 60.2 months, biliary complication rate was lower in the LC group than in the CO group (0% versus 5.2%; P = 0.01), but with no significant difference between the recipient groups. All donors made a complete recovery. In conclusion, the bile ducts of living donors can be dissected safely from the Glissons sheath, and the LC method facilitates bile duct division and has a lower incidence of biliary complication in LDRH without compromising the recipient outcomes. Liver Transplantation 23 448–456 2017 AASLD.

A simplified protocol using rituximab and immunoglobulin for ABO‐incompatible low‐titre living donor liver transplantation

No consensus has been reached regarding optimal treatment strategies for ABO‐incompatible (ABO‐I) living donor liver transplantation (LDLT). We introduce a simplified protocol using rituximab and intravenous immunoglobulin (IVIG).

Impact of preserved collateral veins on small-for-size grafts in living donor liver transplantation: Collateral veins in a small-for-size graft

Graft size is a critical issue in living donor liver transplantation (LDLT). We hypothesized that too much portal flow could possibly be diverted into pre‐existing collateral veins, alleviating small‐for‐size syndrome (SFSS) in LDLT. This study evaluated the impact of the preserved collateral veins in the outcomes of LDLT using a small‐for‐size graft.

Right lobe living donors ages 55 years old and older in liver transplantation

The evidence is insufficient for safe use of elderly donors in adult‐to‐adult living donor liver transplantation (LDLT). The aim of this study was to evaluate the outcomes of right lobe LDLT by donor age (≥55 versus < 55 years). All living donors who underwent right hepatectomy at the authors’ institution between March 2008 and December 2015 were divided into 2 groups: group A with an age ≥ 55 years and group B with an age of <55 years. The selection criteria for elderly donor were preservation of middle hepatic vein, remnant liver volume ≥30%, and no or mild fatty liver. The matching criteria of recipients for the elderly donor grafts were Model for End‐Stage Liver Disease score of <25, graft‐to‐recipient weight ratio of >0.8%, and body mass index of <25 kg/m2. Perioperative data, complications by the Clavien classification, and the outcomes with at least 12 months follow‐up were compared. A total of 42 donors were enrolled in group A and 498 in group B. No significant differences in operative parameters were observed between the 2 groups. The peak postoperative aspartate aminotransferase, alanine aminotransferase, and total bilirubin levels made no difference between the 2 groups. The peak international normalized ratio level was significantly lower in group A than in group B (P = 0.001). All donors recovered completely with no significant differences in overall complications between the 2 groups. All recipients of grafts from donors in group A showed good initial function with no significant differences in 1‐year graft and patient survival or biliary complications between 2 groups. These results provide clinical evidence for feasibility of right hepatectomy in living donors aged ≥ 55 years without compromising donor safety or recipient outcomes. Liver Transplantation 23 1305–1311 2017 AASLD.

High-dose hepatitis B immunoglobulin therapy in hepatocellular carcinoma with hepatitis B virus-DNA/hepatitis B e antigen-positive patients after living donor liver transplantation

AIM To investigate the impact of high-dose hepatitis B immunoglobulin (HBIG) on hepatocellular carcinoma (HCC) and hepatitis B virus (HBV) recurrence and overall survival after living donor liver transplantation (LDLT). METHODS We investigated 168 patients who underwent LDLT due to HCC, and who were HBV-DNA/hepatitis B e antigen (HBeAg) -positive, from January 2008 to December 2013. After assessing whether the patients met the Milan criteria, they were assigned to the low-dose HBIG group and high-dose HBIG group. Using the propensity score 1:1 matching method, 38 and 18 pairs were defined as adhering to and not adhering to the Milan criteria. For each pair, HCC recurrence, HBV recurrence and overall survival were analyzed by the Kaplan-Meier method and the log rank test according to the HBIG dose. RESULTS Among those who met the Milan criteria, the 6-mo, 1-year, and 3-year HCC recurrence-free survival rates were 88.9%, 83.2%, and 83.2% in the low-dose HBIG group and 97.2%, 97.2%, and 97.2% in the high-dose HBIG group, respectively (P = 0.042). In contrast, among those who did not meet the Milan criteria, HCC recurrence did not differ according to the HBIG dose (P = 0.937). Moreover, HBV recurrence and overall survival did not differ according to the HBIG dose among those who met (P = 0.317 and 0.190, respectively) and did not meet (P = 0.350 and 0.987, respectively) the Milan criteria. CONCLUSION High-dose HBIG therapy can reduce HCC recurrence in HBV-DNA/HBeAg-positive patients after LDLT.

Outcomes after liver transplantation in accordance with ABO compatibility: A systematic review and meta-analysis

AIM To evaluate the differences in outcomes between ABO-incompatible (ABO-I) liver transplantation (LT) and ABO-compatible (ABO-C) LT. METHODS A systematic review and meta-analysis were performed by searching eligible articles published before No-vember 28, 2016 on MEDLINE (PubMed), EMBASE, and Cochrane databases. The primary endpoints were graft survival, patient survival, and ABO-I-related complications. RESULTS Twenty-one retrospective observational studies with a total of 8247 patients were included in this meta-analysis. Pooled results of patient survival for ABO-I LT were comparable to those for ABO-C LT. However, ABO-I LT showed a poorer graft survival than ABO-C LT (1-year: OR = 0.66, 95%CI: 0.57-0.76, P < 0.001; 3-year: OR = 0.74, 95% CI 0.64-0.85, P < 0.001; 5-yearr: OR =0.75, 95%CI: 0.66-0.86, P < 0.001). Furthermore, ABO-I LT was associated with more incidences of antibody-mediated rejection (OR = 74.21, 95%CI: 16.32- 337.45, P < 0.001), chronic rejection (OR =2.28, 95%CI: 1.00-5.22, P = 0.05), cytomegalovirus infection (OR = 2.64, 95%CI: 1.63-4.29, P < 0.001), overall biliary complication (OR = 1.52, 95%CI: 1.01-2.28, P = 0.04), and hepatic artery complication (OR = 4.17, 95%CI: 2.26-7.67, P < 0.001) than ABO-C LT. In subgroup analyses, ABO-I LT and ABO-C LT showed a comparable graft survival in pediatric patients and those using rituximab, and ABO-I LT showed an increased acute cellular rejection in cases involving deceased donor grafts. CONCLUSION Although patient survival in ABO-I LT was comparable to that in ABO-C LT, ABO-I LT was inferior to ABO-C LT in graft survival and several complications. Graft survival of ABO-I LT could be comparable to that of ABO-C LT in pediatric patients and those using rituximab.

Mortality after portal vein embolization: Two case reports

Abstract Portal vein embolization (PVE) is increasingly performed worldwide to reduce the possibility of liver failure after extended hepatectomy, by inducing future liver remnant (FLR) hypertrophy and atrophy of the liver planned for resection. The procedure is known to be very safe and to have few procedure-related complications. In this study, we described 2 elderly patients with Bismuth–Corlette type IV Klatskin tumor who underwent right trisectional PVE involving the embolization of the right portal vein, the left medial sectional portal branch, and caudate portal vein. Within 1 week after PVE, patients went into sepsis combined with bile leak and died within 1 month. Sepsis can cause acute liver failure in patients with chronic liver disease. In this study, the common patient characteristics other than sepsis, that is, trisectional PVE; chronic alcoholism; aged >65 years; heart-related comorbidity; and elevated serum total bilirubin (TB) level (7.0 mg/dL) at the time of the PVE procedure in 1 patient, and concurrent biliary procedure, that is, percutaneous transhepatic biliary drainage in the other patient might have affected the outcomes of PVE. These cases highlight that PVE is not a safe procedure. Care should be taken to minimize the occurrence of infectious events because sepsis following PVE can cause acute liver failure. Additionally, prior to performing PVE, the extent of PVE, chronic alcohol consumption, age, comorbidity, long-lasting jaundice, concurrent biliary procedure, etc. should be considered for patient safety.

Living-donor liver retransplantation using the vessels of the previous allograft by intragraft dissection

Retransplantation with the use of a living-donor graft can be the only therapeutic option for patients with irreversible graft failure, especially in regions with limited access to deceased donors, but it can be technically demanding because of severe adhesion around the hepatic hilum and inferior vena cava. We introduce an effective and safe technique to overcome this challenge for right-lobe living-donor liver retransplantation by using the vessels of the previous right liver allograft with the use of intragraft dissection. The technique was used in 2 critically ill patients undergoing the graft failure. The operative times were 360 and 410 minutes. The recipients were discharged on days 18 and 25 with normal liver function. One postoperative complication occurred 3 months after retransplantation: biliary leakage, corrected with the use of percutaneous transhepatic biliary drainage. Both patients were alive with a functioning allograft at last follow-up of >3 years. Intragraft dissection to use the vessels of the previous right-liver allograft can be a useful technique and should be considered for right-lobe living-donor liver retransplantation.