Kwangho Yang

Beneficial Effect of Extracorporeal Membrane Oxygenation on Organ Perfusion During Management of the Unstable Brain-dead Donor: A Case Series

It is well known that the quality of organs retrieved from brain-dead donors (DBDs) is better than those retrieved from circulatory death donors. However, in situations of organ retrieval from marginal DBDs, who are unstable despite intensive care, transplantation outcomes are not good. Organ ischemia is the most important determining factor in decreased organ quality in circulatory death donors and in some DBDs. Extracorporeal membrane oxygenation (ECMO) for management of DBDs can be an emergency countermeasure. The purpose of this report is to relay our experience with four cases of ECMO for DBD management. In all four cases, the donors were unstable and showed clear signs of ischemia despite intensive care, including ventilator use and administration of inotropic agents. Two donors had acute respiratory distress syndrome, and two exhibited dysfunctional oxygen delivery. ECMO was used to improve organ perfusion. ECMO resulted in an increased partial pressure of arterial oxygen increased and decreased lactic acid levels. Vital signs were stabilized, especially in the donors who were bleeding. The organ was successfully retrieved from each donor. Two livers (one of them was split), eight kidneys, and one pancreas were retrieved from four DBDs. All other organs were transplanted successfully, and there were no cases of primary nonfunction or delayed graft function. The ECMO machine is the most powerful supportive device for management of unstable DBDs. The use of ECMO in unstable DBDs can be beneficial in expanding the donor pool as well as improving the quality of retrieved organs.

Complete Regression of Recurrent Advanced Hepatocellular Carcinoma After Liver Transplantation in Response to Sorafenib Treatment: A Case Report

Liver transplantation is a potentially curative treatment for hepatocellular carcinoma. However, patients with recurrent hepatocellular carcinoma after liver transplantation have few treatment options and local treatment may not be feasible. Sorafenib, an orally active multikinase inhibitor approved for the treatment of advanced hepatocellular carcinoma, significantly improves progression-free and overall survival. However, only a few studies have evaluated the efficacy of sorafenib in patients with recurrent hepatocellular carcinoma following liver transplantation. Here, we report a case of a patient with recurrent advanced hepatocellular carcinoma after living donor liver transplantation who achieved complete remission in response to sorafenib treatment. The patient has survived for more than 4 years post-transplantation.

Formation of Collateral Veins in a Graft Pancreas After a Simultaneous Pancreas and Kidney Transplantation: A Case Report

A graft vein thrombosis is the main cause of early graft failure after pancreas transplantation. We report a case of formation of collateral veins in a graft pancreas after transplant. A 30-year-old woman underwent simultaneous pancreas and kidney transplantation. She was discharged 16 days after the operation with good pancreas and kidney function. A total occlusion of the portal vein was discovered on computed tomography (CT) performed at an outpatient clinic. She had no symptoms or signs of hyperglycemia. Venography was attempted for vein thrombectomy but failed. After 2 weeks of heparinization therapy, the edema disappeared and perfusion of the graft pancreas improved. However, the thrombotic occlusion was not resolved on CT. Arteriography of the Y-graft revealed collateral veins. She was discharged with warfarin. She is currently doing well without any symptoms or signs. This is the first reported case of collateral vein formation in a grafted pancreas after pancreas transplantation.

Clinical Impacts of Donor Types of Living vs. Deceased Donors: Predictors of One-Year Mortality in Patients with Liver Transplantation

Transplantation studies about the clinical differences according to the type of donors are mostly conducted in western countries with rare reports from Asians. The aims of this study were to evaluate the clinical impacts of the type of donor, and the predictors of 1-year mortality in patients who underwent liver transplantation (LT). This study was performed for liver transplant recipients between May 2010 and December 2014 at the Pusan National University Yangsan Hospital. A total of 185 recipients who underwent LT were analyzed. Of the 185 recipients, 109 (58.9%) belonged to the living donor liver transplantation (LDLT) group. The median age was 52.4 years. LDLT recipients had lower model for end-stage liver disease (MELD) score compared with better liver function than deceased donor liver transplantation (DDLT) recipients (mean ± standard deviation [SD], 12.5 ± 8.3 vs. 24.9 ± 11.7, respectively; P < 0.001), and had more advanced hepatocellular carcinoma (HCC) (62.4% vs. 21.1%, respectively; P = 0.001). In complications and clinical outcomes, LDLT recipients showed shorter stay in intensive care unit (ICU) (mean ± SD, 10.8 ± 8.8 vs. 23.0 ± 13.8 days, respectively, P < 0.001), ventilator care days, and post-operative admission days, and lower 1-year mortality (11% vs. 27.6%, respectively, P = 0.004). Bleeding and infectious complications were less in LDLT recipients. Recipients with DDLT (P = 0.004) showed higher mortality in univariate analysis, and multi-logistic regression analysis found higher MELD score and higher pre-operative serum brain natriuretic peptide (BNP) were associated with 1-year mortality. This study may guide improved management before and after LT from donor selection to post-operation follow up.

Inferior Vena Cava–Duodenal Drainage in Pancreas Alone Transplantation for Chronic Pancreatitis: A Case Report

Enteric drainage has been the main trend in solitary pancreas transplantation. Compared with bladder drainage, it does not cause metabolic or urologic complications, but there is no way to perform immunologic monitoring, except by graft pancreas biopsy. Additionally, although portal drainage of the graft vein is considered physiological drainage, it has more of a risk for surgical complications. To overcome these disadvantages, we successfully performed inferior vena cava (IVC)-duodenal drainage in pancreas alone transplantation. A 44-year-old man underwent pancreas alone transplantation. He had insulin-dependent diabetes because of chronic pancreatitis, thus he had taken a pancreatic enzyme. After right-sided medial visceral rotation, the IVC was dissected for anastomosis with a graft portal vein. The right common iliac artery was anastomosed with a Y-graft in the pancreas graft. The graft duodenum was anastomosed with recipient duodenum using the side-to-side manner. Postoperatively, he underwent protocol biopsies of the graft duodenum through endoscopy two times. There was no evidence of graft thrombosis or rejection. He had a normal glucose level without any diabetic drugs, and he required no pancreatic enzyme for digestion. The IVC-duodenum drainage procedure was a feasible method for preventing thrombosis and providing an opportunity for direct graft monitoring through endoscopy.

Caudal middle hepatic vein trunk preserved right lobe graft in living donor liver transplantation

Purpose Multiple segment 5 vein (V5) anastomoses are common and inevitable in living donor liver transplantation (LDLT) using modified right lobe (MRL) graft. Sacrifice of segment 4a vein (V4a) can simplify bench work and avoid graft congestion. But it could be harmful to some donors in previous simulation studies. This study aimed to evaluate donor safety in LDLT using caudal middle hepatic vein trunk preserved right lobe (CMPRL) graft. Methods LDLT using MRL grafts were performed on 33 patients (group A) and LDLT using CMPRL grafts were performed on 37 patients (group B). Group B was classified into 2 subgroups by venous drainage pattern of segment 4: V4a dominant drainage group (group B1) and the other group (group B2). Parameters compared between group A donors and group B donors included operation time, bench work time, number and diameter of V5, remnant liver volume and postoperative course. Those were also investigated in group B1 compared with group B2. And, we reviewed postoperative course of the recipients in groups A and B. Results Operation time and bench work time in group B were significantly shorter. There were no significant differences in most postoperative parameters between groups B1 and B2. As a result of recipient, V5 patency rates after LDLT were significantly higher in group B. Conclusion LDLT using CMPRL graft is a safe procedure for living donors. Donors with any type of V4 could be proper candidates for CMPRL graft if remnant liver volume is greater than 30% with minimal fatty change.

CMV specific T cell immunity predicts early viremia after liver transplantation

BACKGROUND Cytomegalovirus (CMV) infection is one of the most important factors affecting liver transplant with direct and indirect effects. However, CMV disease after transplant remains poorly predicted. OBJECTIVE In this study, preoperative CMV-specific cell-mediated immunity was evaluated in recipients of liver transplant in Korea, where most people are seropositive. METHODS A total of 32 patients were enrolled in a prospective study, and blood samples were collected before liver transplant to determine CMV-specific cell-mediated immunity. Testing using ELiSpot IFN-γ (CMVspot) and CMV serology were performed simultaneously. RESULTS CMVspot results showed that 30 recipients had CMV-specific cell-mediated immunity, of which 29 were positive for phosphoprotein 65 and 14 for immediate early protein 1 (IE-1). All patients were positive for CMV IgG before transplantation, and 17 patients had a CMV viremia episode after transplantation. CMVspot showed 100% specificity and positive predictive value, and 11.76% sensitivity to predict CMV viremia. Patients with positive or borderline results for IE-1 did not show viremia two months after transplantation (p = .041). CONCLUSION CMVspot may be helpful in establishing a treatment strategy that includes regular monitoring for risk stratification of CMV reactivation.

Predictors of postoperative infectious complications in liver transplant recipients: experience of 185 consecutive cases

Background/Aims Infections following liver transplant (LT) remain a major cause of mortality. This study was conducted to evaluate risk factors for infection and to review clinical characteristics. Methods Medical records of patients who underwent LT from 2010 to 2014 were retrospectively analyzed. Binary logistic regression analysis was used to investigate risk factors of infection. Kaplan-Meier analysis was used to predict prognosis of infected and non-infected groups. Results Of 185 recipients, 89 patients experienced infectious complications. The median follow-up period was 911 days (range, 9 to 2,031). The infected group had higher 1-year mortality (n = 22 [24.7%] vs. n = 8, [8.3%], p = 0.002), and longer postoperative admission days (mean: 53.7 ± 35.8 days vs. 28.3 ± 13.0 days, p < 0.001), compared to the non-infected group. High preoperative Model for End-Stage Liver Disease (MELD) score (odds ratio [OR], 1.057; 95% confidence interval [CI], 1.010 to 1.105; p = 0.016), deceased-donor type (OR, 5.475; 95% CI, 2.442 to 12.279; p < 0.001), and acute rejection (OR, 3.042; 95% CI, 1.241 to 7.454; p = 0.015) were independent risk factors associated with infection. Intra-abdominal infection (n = 35, 20.8%) was the major infectious complication. Among identified bacteria, Enterococcus species (28.4%) were major pathogens, followed by Escherichia coli and Klebsiella species. Conclusions High preoperative MELD score, deceased-donor type, and acute rejection were risk factors associated with infection. To prevent infections following surgery, it is important to determine the appropriate time of operation before the recipient has a high MELD score.

Pancreas Transplantation After Liver Transplantation: A Case Report

Our aim was to describe the clinical indications, surgical technique, and clinical outcomes of a pancreas transplantation, performed 4 years after liver transplantation, as treatment for new-onset, uncontrolled diabetes mellitus in a 53-year-old man. Liver transplantation was performed for end-stage liver disease secondary to hepatitis B virus infection and hepatocellular carcinoma. The patient had no history of diabetes prior to the liver transplantation. The decision to proceed with a pancreas transplantation was made when the patients blood sugar levels could not be normalized despite insulin doses >100 IU/d. A modified cadaveric transplantation technique was used, with the recipients inferior vena cava dissected for anastomosis with the portal vein of the graft, using a diamond-shaped patch procedure. Moreover, the right common iliac artery was anastomosed with a Y-graft in the pancreas graft, and the duodenum remnant of the graft was anastomosed to the recipients duodenum using a side-to-side procedure. The 6-month postoperative follow-up included repeated endoscopic biopsy of the graft duodenum, with no evidence of thrombosis or rejection of the graft, with glucose level within normal limits without requirement for diabetic drugs. To our knowledge, this is the first reported case of pancreas transplantation after liver transplantation.

Do hepatic-sided tumors require more extensive resection than peritoneal-sided tumors in patients with T2 gallbladder cancer? Results of a retrospective multicenter study

Background: Tumor location is a prognostic factor for survival in patients with T2 gallbladder cancer. However, the optimal extent of resection according to tumor location remains unclear. Methods: We reviewed the records of 192 patients with T2 gallbladder cancer who underwent R0 or R1 resection at 6 institutions. Perioperative and oncologic outcomes were compared according to the extent of resection between hepatic‐sided (n = 93) and peritoneal‐sided (n = 99) tumors. Results: After a median follow‐up of 30 months, the 5‐year overall survival (84.9% vs 71.8%, P = .048) and recurrence‐free survival (74.6% vs 62.2%, P = .060) were greater in peritoneal‐sided T2 patients than in hepatic‐sided T2 patients. Among hepatic‐sided T2 patients, the 5‐year overall survival was greater in patients who underwent radical cholecystectomy including lymph node dissection with liver resection than in patients who underwent lymph node dissection without liver resection (80.3% vs 30.0%, P = .032), and the extent of liver resection was not associated with overall survival (P = .526). Lymph node dissection without liver resection was an independent prognostic factor for overall survival in hepatic‐sided T2 gallbladder cancer (hazard ratio 5.009, 95% confidence interval 1.512–16.596, P = .008). In peritoneal‐sided T2 patients, the 5‐year overall survival was not significantly different between the lymph node dissection with liver resection and the lymph node dissection without liver resection subgroups (70.5% vs 54.8%, P = .111) and the extent of lymph node dissection was not associated with overall survival (P = .395). Conclusion: In peritoneal‐sided T2 gallbladder cancer, radical cholecystectomy including lymph node dissection without liver resection is a reasonable operative option. Radical cholecystectomy including lymph node dissection with liver resection is suitable for hepatic‐sided T2 gallbladder cancer.