Kwang-Min Park

Seventeen adult-to-adult living donor liver transplantations using dual grafts.

THE MAJOR limitation of adult-to-adult living donor liver transplantation (A-A LDLT) is the adequacy of the graft size. It has been known that 50% of the standard liver volume of the recipient is the minimum liver graft volume required to provide adequate functional hepatocytes. A left lobe from a relatively small volunteer donor will not meet the metabolic demands of a larger recipient. The possible solutions to this problem are to increase the extent of resection in the donor by harvesting the right lobe of the liver, which accounts for 60% to 70% of the total liver mass, to apply an auxiliary partial orthotopic liver transplantation (APOLT), or to implant dual grafts into one recipient. The right lobe harvest in the donor is not always safe, depending mainly on the volume of the remaining left lobe. Even though the donor has sufficiently large right lobe that is adequate as a graft for an adult recipient, the remaining left lobe may be too small to produce a threat to donor safety in many occasions. In this instance, the donor cannot be allowed to donate either side of the liver lobe for a large-size adult recipient. As an alternative, dual left lobe or left lateral segment from two living donors can solve the problem of graft-size insufficiency and guarantee donor safety. Furthermore, if the large-size recipient requires a bigger graft liver volume than the volume of the sum from two potential living donors’ left lobes, and if the right lobe harvested from one of two potential donors seems to be safe, one right lobe and one left lobe from two donors can be transplanted into a single recipient to avoid a small-forsize graft problem. The present study aims to introduce the usefulness of dual-graft A-A LDLT by review of our single-center experience.

Hepatic venous congestion in living donor liver transplantation: Preoperative quantitative prediction and follow‐up using computed tomography

Hepatic venous congestion (HVC) has not been assessed quantitatively prior to hepatectomy and its resolving mechanism has not been fully analyzed. We devised and verified a new method to predict HVC, in which HVC was estimated from delineation of middle hepatic vein (MHV) tributaries in computed tomography (CT) images. The predicted HVC was transferred to the right hepatic lobes of 20 living donors using a paper scale, and it was compared with the actual observed HVC that occurred after parenchymal transection and arterial clamping. The evolution of HVC from its emergence to resolution was followed up with CT. Volume proportions of the predicted and observed HVC were 31.7 ± 6.3% and 31.3 ± 9.4% of right lobe volume (RLV) (P = .74), respectively, which resulted in a prediction error of 3.8 ± 3.7% of RLV. We observed the changes in the HVC area of the right lobes both in donors without MHV trunk and in recipients with MHV reconstruction. After 7 days, the HVC of 33.5 ± 7.7% of RLV was changed to a computed tomography attenuation abnormality (CTAA) of 28.4 ± 5.3% of RLV in 12 donor remnant right lobes, and the HVC of 29.1 ± 11.5% of RLV was reduced to a CTAA of 9.3 ± 3.2% of RLV in 7 recipient right lobe grafts with MHV reconstruction. There was no parenchymal regeneration of the HVC area in donor remnant livers during first 7 days. In conclusion, we believe that this CT‐based method for HVC prediction deserves to be applied as an inevitable part of preoperative donor evaluation. The changes in CTAA observed in the right lobes of donors and recipients indicate that MHV reconstruction can effectively decrease the HVC area. (Liver Transpl 2004;10:763–770.)

Enucleation for benign or low-grade malignant lesions of the pancreas: Single-center experience with 65 consecutive patients

INTRODUCTION Standard resection for benign and borderline neoplasms of the pancreas is associated with a substantial risk of postoperative morbidity and long-term functional impairment, whereas enucleation leads to less morbidity and preserves healthy parenchyma as well as pancreatic function. The aim of this study was to evaluate the postoperative clinical outcomes and long-term functional and oncologic results after pancreatic enucleation, and to compare the clinical results of laparoscopic and open enucleation. METHODS From March 2005 to December 2013, 65 cases of enucleation of benign tumors in the pancreas were identified through a retrospective review of medical records. RESULTS Most of the patients were women (73.8 %), and the median age was 52.7 years (interquartile range 43.1-60.9 years). Median tumor size was 2.5 cm (interquartile range 1.6-3.8 cm). The most common indication for enucleation was pancreatic neuroendocrine tumor (24, 36.9%). A clinically relevant pancreatic fistula (International Study Group on Pancreatic Fistula grade B, C) was reported in 6 patients (9.2%). The patients with tumors of the pancreatic neck had more complications after enucleation than those with tumors at other locations (3/4, 75%). There were no differences of clinical outcomes between open and laparoscopic enucleation groups. At a median follow-up of 58.7 months there was one case of new-onset diabetes, and there were no recurrences or deaths. CONCLUSION Enucleation is a safe and effective procedure for the treatment of benign and borderline pancreatic neoplasms. It preserves pancreatic function and is not associated with recurrence. The incidence of postoperative complications, including pancreatic fistula, is acceptable. Laparoscopic enucleation seems to be a feasible and safe approach associated with favorable perioperative outcomes for the selected patients.

Preoperative evaluation of biliary anatomy of donor in living donor liver transplantation by conventional nonenhanced magnetic resonance cholangiography

Detailed preoperative evaluation of the biliary anatomy of the donor in living donor liver transplantation (LDLT) can minimize postoperative morbidity in the recipient and maximize safety for the donor. We prospectively evaluated the diagnostic accuracy and clinical usefulness of nonenhanced conventional magnetic resonance cholangiography (MRC) for depicting the biliary anatomy of LDLT donors. MRC and intraoperative cholangiography (IOC) examinations of 111 donors were performed between August 2005 and February 2006. We observed the classical branching pattern of the biliary system in 67 subjects (60.4%), with the remaining 44 subjects (39.6%) showing anatomical variations. MRC showed accurate anatomy of the biliary system, using IOC as the reference standard, in 98 (88.3%) subjects. MRC had a sensitivity in differentiating normal from variant anatomy of 95.5%, specificity of 95.2%, a positive predictive value of 96.8% and a negative predictive value of 93.3%. The agreement between MRC and IOC findings, as evaluated by κ‐value (0.865) was statistically significant (P < 0.001). In conclusion, the diagnostic accuracy of conventional nonenhanced MRC is sufficient for this method to be used for the preoperative evaluation of biliary anatomy in LDLT donor candidates.

Prognostic factors in 151 patients with surgically resected non-functioning pancreatic neuroendocrine tumours.

Recently, non‐functioning pancreatic neuroendocrine tumors (NF‐PNETs) are increasing. It is important to know about the prognostic factors and long‐term survival rates in patients with NF‐PNET for the management of these diseases.

Surgical impact of an inferior right hepatic vein on right anterior sectionectomy and right posterior sectionectomy

In hepatocellular carcinoma, anatomical resection is important because of portal spread. In right anterior sectionectomy (RAS) and right posterior sectionectomy (RPS), the right hepatic vein (RHV) may not correspond with the intersectional plane if an inferior RHV (IRHV) is present. The aim of this study was to evaluate the influence of the IRHV on the exposure of the RHV retrospectively.