Justin Sangwook Ko

Effects of Repeat Bolus Ethanol Injections on Cardiopulmonary Hemodynamic Changes during Embolotherapy of Arteriovenous Malformations of the Extremities

PURPOSE This study was designed to investigate the effects of repeat bolus absolute ethanol injections on cardiopulmonary hemodynamic changes during ethanol embolotherapy of inoperable congenital arteriovenous (AV) malformations in the extremities. MATERIALS AND METHODS Thirty adult patients (14 male, 16 female; age range, 22-51 years) who underwent ethanol embolotherapy of extremity AV malformations were enrolled in the study. A pulmonary artery catheter was used to measure hemodynamic profiles at baseline (T(baseline)), immediately before (T(pre)) and after (T(post)) a bolus injection of absolute ethanol, at the time of the maximum mean pulmonary arterial pressure (PAP) value during a session (T(highest)), 10 minutes after the final injection (T(final)), and after restoration of spontaneous breathing (T(resp)). RESULTS The systolic, mean, and diastolic PAP (P < .01, P < .01, and P < .01, respectively) and the systemic vascular resistance index (P < .05) and pulmonary vascular resistance index (PVRI; P < .05) of T(highest) and T(resp) were significantly higher than values for T(final). The volume of a single bolus injection of absolute ethanol from 0.023 to 0.175 mL/kg of body weight showed that the systolic PAP (P = .02), pulmonary capillary wedge pressure (P = .02), and PVRI (P < .01) significantly increased in accordance with the increased single volume of absolute ethanol. A significant increase of the right ventricular end-diastolic volume index and right ventricular end-systolic volume index were observed at a dose of more than 0.14 mL/kg of body weight for a single bolus injection of absolute ethanol. CONCLUSIONS During ethanol embolotherapy of extremity AV malformations, significant hemodynamic changes can arise during a bolus injection of absolute ethanol. Cardiopulmonary hemodynamic profiles should be monitored closely after a bolus injection of more than 0.14 mL/kg of body weight of absolute ethanol.

Intrathecal morphine combined with intravenous patient‐controlled analgesia is an effective and safe method for immediate postoperative pain control in live liver donors

The healthy condition of living donors makes their tolerance to pain particularly low, and clinicians are often challenged to come up with an analgesic technique that is effective yet ensures donor safety. This study compared, in donor right hepatectomy, the efficacy and safety of preoperative intrathecal morphine (ITM) combined with intravenous patient‐controlled analgesia (IV‐PCA) with IV‐PCA alone. Forty adult patients were randomly allocated into 2 groups: ITM+IV‐PCA group (n = 20) and IV‐PCA‐only group (n = 20). Patients in the ITM+IV‐PCA group received morphine sulfate (400 μg). The visual analog scale (VAS) at rest and when coughing and supplementary meperidine and IV‐PCA (fentanyl) consumption were assessed at 2, 4, 6, 8, 10, 12, 18, 24, 30, 36, 42, 48 56, 64, and 72 hours after surgery. Also, side effects such as sedation, dizziness, nausea, vomiting, pruritus, and respiratory depression were evaluated. The ITM+IV‐PCA group showed significantly less pain at rest and when coughing for up to 30 hours and 24 hours, respectively. Cumulative postoperative consumption of meperidine and IV‐PCA (fentanyl) were significantly less in the ITM+IV‐PCA group. The incidence of side effects were comparable between the 2 groups except for pruritus; its incidence was significantly higher in the ITM+IV‐PCA group during the first 24 hours, but no treatment was required due to its mild severity. The results of our study suggest that preoperative ITM combined with IV‐PCA may be considered as an effective and safe pain management regimen in living liver donors who have characteristics of low tolerance to pain and postoperative coagulation derangement. Liver Transpl 15:381–389, 2009.

The effect of alkaline phosphatase and intrahepatic metastases in large hepatocellular carcinoma

BackgroundHepatectomy is the standard treatment for HCC. However, large HCC poses a difficult challenge because of the technical complexity of surgical resection and the fear of postoperative hepatic decompensation. We analyzed the outcome and prognostic factors in patients with large hepatocellular carcinoma (HCC ≥10 cm) after surgery.MethodsWe retrospectively investigated the medical records of 91 patients who had undergone hepatectomy between January 2006 and June 2010. A survival analysis was performed utilizing the Kaplan-Meier method and prognostic factors were evaluated using Cox regression analysis.ResultsOf the 91 patients evaluated, most tumors were associated with hepatitis B virus (HBV). The median tumor size was 12.3 cm (range, 10 to 21 cm), with microvascular invasion present in most patients. The postoperative mortality rate was 2.2%. The median disease-free survival and overall survival were six months and 41 months. The one-year, two-year, and three-year disease-free survival rates were 33.5%, 29.3%, and 18.8%, respectively. The one-year, two-year, and three-year overall survival rates were 73.9%, 63.7%, and 54.8%, respectively. Of the 89 surviving patients, 69 patients (77.5%) developed HCC recurrence during the mean follow-up period of 23.4 ± 15.9 months. On multivariate analysis, the statistically significant factors that predicted HCC recurrence were ALP ≥ 80 IU/mL (P = 0.009) and intrahepatic metastases (P = 0.013).ConclusionsOur study suggests that preoperative ALP levels (≥ 80 IU/L) and intrahepatic metastases could be utilized to monitor and predict recurrence in HCC patients.

The effects of desflurane and sevoflurane on hepatic and renal functions after right hepatectomy in living donors

We compared postoperative hepatic and renal functions between the two inhalational anesthetics, desflurane and sevoflurane in living donors undergoing right hepatectomy. Seventy‐four adult donors were randomly allocated into Des group (n = 37) and sevo group (n = 37). Before the induction of anesthesia, morphine sulfate 400 μg was injected intrathecally. Anesthesia was maintained with one minimum alveolar concentration (MAC) of deflurane or sevoflurane plus continuous intravenous remifentanil. Liver and renal function tests were performed and analysed at preoperative period, immediately after operation, and on 1st, 2nd, 3rd, 5th, 7th, and 30th postoperative days (PODs). Aspartate aminotransferase (AST) showed significant elevations from the day of surgery to POD 3 and alanine aminotransferase (ALT) was significantly elevated on POD 1 and POD 3 in the sevo group. Albumin level was significantly lower on POD 2 in the sevo group. Creatinine was significantly higher on POD 3 and POD 30 and estimated glomerular filtration ratio was significantly lower on POD 3 and POD 30 in the sevo group. No patient developed hepatic or renal failures. The results of our study showed better postoperative hepatic and renal function test with desflurane than sevoflurane at equivalent dose of 1 MAC in living donors undergoing right hepatectomy, but further study is required to evaluate clinical importance.

Long‐term results for living donor liver transplant recipients with hepatocellular carcinoma using intraoperative blood salvage with leukocyte depletion filter

Massive intraoperative bleeding during liver transplantation often requires large amounts of blood products. The goal of this study was to investigate long‐term outcomes of living donor liver transplantation (LDLT) recipients with hepatocellular carcinoma (HCC) who underwent intraoperative use of intraoperative blood salvage (IBS) and leukocyte depletion filter (LDF). In this study, we included 230 LDLT recipients with HCC from two transplantation centers, between February 2002 and December 2007. Group 1 patients (n = 121) underwent intraoperative IBS with LDF and group 2 patients (n = 109) did not. The amount of autotransfused, filtered red blood cells (RBCs) in group 1 was 1590.2 ± 1486.8 ml, which corresponded to 5.9 units of allogenic leukocyte‐depleted RBCs saved. The incidences of renal dysfunction, postoperative bleeding, and urinary tract infection in group 2 were higher than in group 1 (P < 0.05). Recurrence‐free survival rates for 1, 3, and 5 years were 91.3%, 83.3%, and 83.3%, respectively, in group 1, and 84.6%, 79.0%, and 77.4%, respectively, in group 2 (P = 0.314). IBS using LDF does not increase the risk of cancer recurrence during LDLT for recipients with HCC. Therefore, the use of IBS with LDF appears to be safe for LDLT recipients with HCC.

Prediction of the Effect of Injected Ethanol on Pulmonary Arterial Pressure during Sclerotherapy of Arteriovenous Malformations: Relationship with Dose of Ethanol

PURPOSE To prospectively evaluate the effect of injected ethanol on pulmonary artery pressure during embolosclerotherapy of arteriovenous malformations (AVMs). MATERIALS AND METHODS This prospective study was conducted in 16 male and 14 female patients (37 sessions; mean age, 34 years; age range, 17-67 years) with AVMs during a 2-year period. The authors measured pulmonary artery pressure via a pulmonary artery catheter and ethanol levels from the pulmonary and radial arteries simultaneously within 3 minutes after each ethanol injection. The authors analyzed the relationship between pulmonary artery pressure and ethanol levels obtained from pulmonary and radial arteries with respect to both single and cumulative doses of ethanol injected. Retrospectively, patients were divided into two groups-those treated with and those treated without vascular occlusion techniques. RESULTS The radial arterial ethanol level showed good correlation with the pulmonary arterial ethanol level (r = 0.7). Single dose per injection was statistically related with pulmonary artery pressure (r = 0.5 vs 0.1 and P < .05 vs .29, respectively, in patients treated without and patients treated with vascular occlusion techniques), and the correlation coefficient between cumulative dose and pulmonary artery pressure was 0.2 and 0.3 in respective cases (P < .05 for both). The mean pulmonary artery pressure correlated with pulmonary arterial ethanol level irrespective of the use of vascular occlusion (r = 0.6 for both groups). CONCLUSIONS Pulmonary artery pressure reflected the pulmonary arterial ethanol level and was positively related to the dose of ethanol. Single dose per injection was predictive of pulmonary artery pressure only in patients treated without vascular occlusion techniques.

Association Between Intraoperative Platelet Transfusion and Early Graft Regeneration in Living Donor Liver Transplantation.

Objective: To evaluate the association between anesthetic management before and after graft reperfusion and early graft regeneration in living donor liver transplantation (LDLT). Background: Sufficient graft regeneration is essential for the success of LDLT. Diverse signals start to trigger liver regeneration immediately after graft reperfusion. Methods: Graft volume at 14 ± 2 days after LDLT was measured in 379 consecutive recipients using computed tomography images with 3-dimensional reconstruction. The association between anesthetic variables and the degree of graft regeneration for 2 weeks was analyzed using simple and multiple linear regressions. The anesthetic variables included hemodynamics, laboratory measurements, vasoactive drugs, and blood products transfusion. Results: The degree of graft regeneration for 2 weeks was 52% in median and ranged from 5% to 123%. Platelet transfusion was identified as the sole independent anesthetic factor contributing to graft regeneration. Platelet concentrate transfusion of 1 to 6 units vs none was correlated with a 6.5% increase in graft regeneration (P = 0.012). Platelet concentrate transfusion of more than 6 units vs none was further correlated with an 18.4% increase in regeneration (P < 0.001). In the subgroup of recipients without intraoperative platelet transfusion, mean platelet count measured during the intraoperative reperfusion phase was positively associated with graft regeneration (P = 0.033). Conclusions: Graft regeneration after LDLT increased in relation to a graded increase in the amount of transfused platelets and higher postreperfusion platelet counts during surgery. These results offer additional evidence regarding the important role of platelets in initiating liver regeneration and, furthermore, the indications for and the benefits vs risks of platelet transfusion during LDLT.

Utility of uncalibrated femoral stroke volume variation as a predictor of fluid responsiveness during the anhepatic phase of liver transplantation

We evaluated the value of the stroke volume variation (SVV) calculated with the Vigileo monitor, which recently has been increasingly advocated for fluid management, as a predictor of fluid responsiveness during the anhepatic phase of liver transplantation (LT). We also compared SVV to the central venous pressure (CVP) and pulmonary arterial occlusion pressure (PAOP) in patients. Thirty‐three adult recipients scheduled for elective living donor LT were enrolled in this study. Twenty minutes after the start of the anhepatic phase, the CVP, PAOP, approximate inferior vena caval pressure, femoral SVV, and cardiac output values were measured before and 12 minutes after fluid loading. Fluid loading was performed with a 6% hydroxyethyl starch solution (10 mL/kg). The responders were defined as patients whose cardiac index increased ≥15% after fluid loading. Receiver operating characteristic (ROC) analysis showed that only femoral SVV (area under the curve = 0.894, P = 0.0001) could be used to predict fluid responsiveness during the anhepatic phase of LT. The area under the ROC curve for femoral SVV was 0.894 (P = 0.0001), and it was significantly larger than those for CVP (area under the curve = 0.576, P = 0.004) and PAOP (area under the curve = 0.670, P = 0.021). Femoral SVV >8% identified the responders with a sensitivity of 89% and a specificity of 80%. Our results suggest that femoral SVV derived with the Vigileo monitor would be useful for fluid management during the anhepatic phase in LT recipients. Liver Transpl 17:53–59, 2011.

Effect of combined single-injection femoral nerve block and patient-controlled epidural analgesia in patients undergoing total knee replacement.

Purpose Total knee replacement is one of the most painful orthopedic procedures, and effective pain relief is essential for early mobility and discharge from hospital. The aim of this study was to evaluate whether addition of single-injection femoral nerve block to epidural analgesia would provide better postoperative pain control, compared to epidural analgesia alone, after total knee replacement. Materials and Methods Thirty-eight patients received a single-injection femoral nerve block with 0.25% levobupivacaine (30 mL) combined with epidural analgesia (femoral nerve block group) and 40 patients received epidural analgesia alone (control group). Pain intensity and volume of patient-controlled epidural analgesia medication and rescue analgesic requirements were measured in the first 48 hours after surgery at three time periods; 0-6 hours, 6-24 hours, and 24-48 hours. Also, side effects such as nausea, vomiting, and pruritus were evaluated. Results Median visual analog scale at rest and movement was significantly lower until 48 hours in the femoral nerve block group. Patient-controlled epidural analgesia volume was significantly lower throughout the study period, however, rescue analgesia requirements were significantly lower only up to 6 hours in the femoral nerve block group. The incidences of nausea and vomiting and rescue antiemetic requirement were significantly lower in the femoral nerve block group up to 6 hours. Conclusion The combination of femoral nerve block with epidural analgesia is an effective pain management regimen in patients undergoing unilateral total knee replacement.

Single hepatocellular carcinoma ≤ 3 cm in left lateral segment: liver resection or radiofrequency ablation?

AIM To evaluate the long-term results of radiofrequency ablation (RFA) compared to left lateral sectionectomy (LLS) in patients with Child-Pugh class A disease for the treatment of single and small hepatocellular carcinoma (HCC) in the left lateral segments. METHODS We retrospectively reviewed the data of 133 patients with single HCC (≤ 3 cm) in their left lateral segments who underwent curative LLS (n = 66) or RFA (n = 67) between 2006 and 2010. RESULTS The median follow-up period was 33.5 mo in the LLS group and 29 mo in the RFA group (P = 0.060). Most patients had hepatitis B virus-related HCC. The hospital stay was longer in the LLS group than in the RFA group (8 d vs 2 d, P < 0.001). The 1-, 2-, and 3-year disease-free survival and overall survival rates were 80.0%, 68.2%, and 60.0%, and 95.4%, 92.3%, and 92.3%, respectively, for the LLS group; and 80.8%, 59.9%, and 39.6%, and 98.2%, 92.0%, and 74.4%, respectively, for the RFA group. The disease-free survival curve and overall survival curve were higher in the LLS group than in the RFA group (P = 0.012 and P = 0.013, respectively). Increased PIVKA-II levels and small tumor size were associated with HCC recurrence in multivariate analysis. CONCLUSION Liver resection is suitable for single HCC ≤ 3 cm in the left lateral segments.