Kwang-Woong Lee

Percutaneous Transsplenic Access to the Portal Vein for Management of Vascular Complication in Patients with Chronic Liver Disease

PurposeTo evaluate the safety and feasibility of percutaneous transsplenic access to the portal vein for management of vascular complication in patients with chronic liver diseases.MethodsBetween Sept 2009 and April 2011, percutaneous transsplenic access to the portal vein was attempted in nine patients with chronic liver disease. Splenic vein puncture was performed under ultrasonographic guidance with a Chiba needle, followed by introduction of a 4 to 9F sheath. Four patients with hematemesis or hematochezia underwent variceal embolization. Another two patients underwent portosystemic shunt embolization in order to improve portal venous blood flow. Portal vein recanalization was attempted in three patients with a transplanted liver. The percutaneous transsplenic access site was closed using coils and glue.ResultsPercutaneous transsplenic splenic vein catheterization was performed successfully in all patients. Gastric or jejunal varix embolization with glue and lipiodol mixture was performed successfully in four patients. In two patients with a massive portosystemic shunt, embolization of the shunting vessel with a vascular plug, microcoils, glue, and lipiodol mixture was achieved successfully. Portal vein recanalization was attempted in three patients with a transplanted liver; however, only one patient was treated successfully. Complete closure of the percutaneous transsplenic tract was achieved using coils and glue without bleeding complication in all patients.ConclusionPercutaneous transsplenic access to the portal vein can be an alternative route for portography and further endovascular management in patients for whom conventional approaches are difficult or impossible.

Long‐term outcome of endovascular intervention in hepatic venous outflow obstruction following pediatric liver transplantation

The purpose of our study was to address the long‐term outcome of angioplasty and stent placement for hepatic venous outflow obstruction following pediatric liver transplantation. From October 1999 to December 2011, 20 stenotic lesions were confirmed to constitute hepatic venous outflow obstruction in 18 pediatric patients (13 boys, 5 girls) among 152 pediatric patients following liver transplantation and were managed with endovascular intervention. Stent placement was favored over additional angioplasty in patients of preadolescent or adolescent age (>8 years old), after 1 or 2 sessions of balloon angioplasty. The primary patency and assisted primary patency were estimated using the Kaplan‐Meier method. A total of 32 procedures (24 balloon angioplasties, 8 stent placements) were conducted. The technical success rate was 90.6% (29/32). Clinical success was achieved in 15 of 18 patients (clinical success rate of 83.3%). Major complications did not occur in our study. Median follow‐up was 91.5 months (interquartile range, 54.7‐137.3 months) for the 18 patients. The 1‐year, 3‐year, 5‐year, and 10‐year primary patencies of the 20 treated lesions were 63.5%, 57.8%, 57.8%, and 57.8%, respectively. The 1‐year, 3‐year, 5‐year, and 10‐year assisted‐primary patencies of the lesions were 100%, 100%, 100%, and 100%, respectively. Of the 6 patients of preadolescent or adolescent age, 5 patients underwent stent placement procedures, and the stents were patent during the follow‐up period of 57.3‐162.5 months (median, 72.7 months). In conclusion, endovascular intervention is very effective in hepatic venous outflow obstruction following pediatric liver transplantation. In addition, early stent placement in patients of preadolescent or adolescent age can provide a safe and favorable long‐term outcome. Liver Transpl 21:1219‐1226, 2015.

Hepatic stiffness measurement by using MR elastography: prognostic values after hepatic resection for hepatocellular carcinoma

AbstractPurposeTo evaluate prognostic value of hepatic stiffness (HS) measurement using MR elastography (MRE) in patients with hepatocellular carcinoma (HCC) treated by hepatic resection (HR).MethodsWe enrolled 144 patients with Barcelona Clinic Liver Cancer stage A HCCs initially treated by HR who underwent preoperative liver MRE between January 2010 and June 2013. HS values were measured using MRE. Receiver operating characteristics (ROC) and multivariate logistic regression analyses were used to determine significant predictive factors for posthepatecomy liver failure (PHLF). Overall survival (OS) was analyzed by evaluating prognostic factors using the Kaplan–Meier method and Cox proportional hazard regression model.ResultsAfter HR, 43 patients (29.9xa0%) experienced PHLF. HS values were significant predictive factors for PHLF. In ROC analysis, the area under the curve of HS was 0.740 (Pu2009=u20090.001) for PHLF. Thirty-one patients had HS valuesu2009≥u20094.02 kPa; the estimated 1, 3, 5-year survival were 90.0xa0%, 74.7xa0% and 65.4xa0%, respectively, versus 98.1xa0%, 96.5xa0% and 96.5xa0% in 113 patients with HS valuesu2009<u20094.02 kPa (Pu2009=u20090.015). An HS valueu2009≥u20094.02 kPa was the only significant affecting factor for OS.ConclusionHS values measured by MRE could predict PHLF development post-HR. Furthermore, an HS value ≥4.02 kPa was a significant predicting factor for poor OS post-HR.Key Points• Hepatic stiffness value was a predictive factor for developing posthepatectomy liver failuren • Hepatic stiffness value was a significant affecting factor for OSn • Hepatic stiffness valueu2009≥u20094.02 kPa was a predictive factor for poor OS

Clinical and pathological significance of ROS1 expression in intrahepatic cholangiocarcinoma

BackgroundMore knowledge about genetic and molecular features of cholangiocarcinoma is needed to develop effective therapeutic strategies. We investigated the clinical and pathological significance of ROS1 expression in intrahepatic cholangiocarcinoma.MethodsOne hundred ninety-four patients with curatively resected intrahepatic cholangiocarcinoma were included in this study. Tumor tissue specimens were collected and analyzed for ROS1 gene rearrangement using fluorescence in situ hybridization (FISH) and ROS1 protein expression using immunohistochemistry (IHC).ResultsROS1 immunohistochemistry was positive (moderate or strong staining) in 72 tumors (37.1xa0%). ROS1 protein expression was significantly correlated with well differentiated tumors, papillary or mucinous histology, oncocytic/hepatoid or intestinal type tumors, and periductal infiltrating or intraductal growing tumors (vs. mass-forming cholangiocarcinoma). ROS-expressing tumors were associated with better disease-free survival (30.1xa0months for ROS1 expression (+) tumors vs. 9.0xa0months for ROS1 (−) tumors, pu2009=u20090.006). Moreover, ROS1 expression was an independent predictor of better disease-free survival in a multivariate analysis (HR 0.607, 95xa0% CI 0.377–0.976; pu2009=u20090.039). Although break-apart FISH was successfully performed in 102 samples, a split pattern indicative of ROS1 gene rearrangement was not found in the examined samples.ConclusionROS1 protein expression was associated with well-differentiated histology and better survival in our patients with resected intrahepatic cholangiocarcinoma. ROS1 gene rearrangement by break-apart FISH was not found in the examined samples.

Outcomes for patients with HCV after liver transplantation in Korea: a multicenter study

Purpose HCV-related liver disease is the most common indication for liver transplantation (LT) in Western countries, whereas HCV LT is rare in Korea. We conducted a survey of HCV RNA-positive patients who underwent LT and investigated the prognostic factors for patient survival and the effects of immunosuppression. Methods We retrospectively reviewed the multicenter records of 192 HCV RNA-positive patients who underwent LT. Results The 1-, 3-, and 5-year overall survival rates were 78.8%, 75.3%, and 73.1%, respectively. Excluding the cases of hospital mortality (n = 23), 169 patients were evaluated for patient survival. Most patients were genotype 1 (n = 111, 65.7%) or genotype 2 (n = 42, 24.9%). The proportion of living donors for LT (n = 135, 79.9%) was higher than that of deceased donors (deceased donor liver transplantation [DDLT], n = 34, 20.1%). The median donor and recipient ages were 32 years and 56 years, respectively. Twenty-eight patients (16.6%) died during the observation period. Seventy-five patients underwent universal prophylaxis and 15 received preemptive therapy. HCV recurrence was detected in 97 patients. Recipients who were older than 60, received DDLT, used cyclosporine, or suffered acute rejection had lower rates of survival. Conclusion Patent survival rates of HCV patients after LT in Korea were comparable with other countries.

Longterm outcomes of stent placement for hepatic venous outflow obstruction in adult liver transplantation recipients

The purpose of this study was to evaluate the longterm outcomes of stent placement for a hepatic venous outflow obstruction in adult liver transplantation recipients. From June 2002 to March 2014, 23 patients were confirmed to have a hepatic venous outflow obstruction after liver transplantation (18 of 789 living donors [2.3%] and 5 of 449 deceased donors [1.1%]) at our institute. Among these patients, stent placement was needed for 16 stenotic lesions in 15 patients (12 males, 3 females; mean age, 51.7 years). The parameters that were documented retrospectively were technical success, clinical success, complications, recurrence, and the patency of the stent. The technical success rate was 100% (16/16). Clinical success was achieved in 11 of the 15 patients (73.3%). A major complication occurred in only 1 patient—a hepatic vein laceration during the navigation of the occluded segment. The median follow‐up period was 33.5 months (range, 0.5‐129.3 months), and the overall 1‐, 3‐, and 5‐year primary patency rates of the stent were all 93.8%. One case of occlusion of the stent without clinical signs and symptoms was observed 5 days after the initial procedure. In this patient, the stent was recanalized by balloon angioplasty and showed patent lumen for 48 months of the subsequent follow‐up period. In conclusion, stent placement is a safe and effective treatment modality with favorable longterm outcomes to treat hepatic venous outflow obstruction in adult liver transplantation recipients. Liver Transplantation 22 1554–1561 2016 AASLD.

Additional values of high-resolution gadoxetic acid-enhanced MR cholangiography for evaluating the biliary anatomy of living liver donors: Comparison with T 2-weighted MR cholangiography and conventional gadoxetic acid-enhanced MR cholangiography: sFOV HR T 1W MRC on Living Donor Biliary Anatomy

To determine the incremental value of small field of view (sFOV) high‐resolution (HR) gadoxetic acid‐enhanced 3D T1‐weighted (W) magnetic resonance cholangiography (MRC) for evaluating the biliary anatomy of potential living donors by comparing it to T2W‐MRC.

Increased survival in hepatitis c patients who underwent living donor liver transplant: a case-control study with propensity score matching

Purpose There is no consensus regarding the difference in outcomes of HCV in patients who receive living donor liver transplantation (LDLT) or compared to deceased donor liver transplantation (DDLT). The aims of this study were to compare characteristics between LDLT and DDLT groups and to identify risk factors affecting patient survival. Methods We retrospectively reviewed the multicenter records of 192 HCV RNA-positive patients who underwent liver transplantation. Results Thirty-five patients underwent DDLT, and 146 underwent LDLT. The 1-, 3-, and 5-year patient survival rates were 66.7%, 63.0%, and 63.0% in the DDLT group and 86.1%, 82.3%, and 79.5% in the LDLT group (P = 0.024), respectively. After propensity matching, the patient survival curve of the LDLT group was higher than that of the DDLT group. However, there was no statistically significant difference in patient survival between the 2 groups (P = 0.061). Recipient age ≥ 60 years, LDLT, and use of tacrolimus were positively associated with patient survival in multivariate analyses. Conclusion LDLT appears to be suitable for HCV-infected patients if appropriate living donor is available.

Immunosuppression status of liver transplant recipients with hepatitis C affects biopsy-proven acute rejection

Background/Aims The relationship between patient survival and biopsy-proven acute rejection (BPAR) in liver transplant recipients with hepatitis C remains unclear. The aims of this study were to compare the characteristics of patients with and without BPAR and to identify risk factors for BPAR. Methods We retrospectively reviewed the records of 169 HCV-RNA-positive patients who underwent LT at three centers. Results BPAR occurred in 39 (23.1%) of the HCV-RNA-positive recipients after LT. The 1-, 3-, and 5-year survival rates were 92.1%, 90.3%, and 88.5%, respectively, in patients without BPAR, and 75.7%, 63.4%, and 58.9% in patients with BPAR (P<0.001). Multivariate analyses showed that BPAR was associated with the non-use of basiliximab and tacrolimus and the use of cyclosporin in LT recipients with HCV RNA-positive. Conclusion The results of the present study suggest that the immunosuppression status of HCV-RNA-positive LT recipients should be carefully determined in order to prevent BPAR and to improve patient survival.