Kyung-Suk Suh

Liver transplantation for adult patients with hepatocellular carcinoma in Korea: Comparison between cadaveric donor and living donor liver transplantations

Current selection criteria of liver transplantation (LT) for patients with hepatocellular carcinoma (HCC) were derived from the outcomes of cadaveric donor LT (CDLT). We tried to assess the applicability of such criteria to living donor LT (LDLT) through a comparative study between CDLT and LDLT. We analyzed the outcomes of 312 HCC patients who underwent LT at 4 Korean institutions during 1992 to 2002. There were no gross differences of tumor characteristics between CDLT group (n = 75) and LDLT group (n = 237). Overall 3‐year survival rate (3‐YSR) was 61.1% after CDLT and 73.2% after LDLT including 38 cases of perioperative mortality. Comparison of HCC recurrence curves did not reveal any statistical difference between these 2 groups. Patient survival period till 50% mortality after HCC recurrence was 11 months after CDLT and 7 months after LDLT. Significant risk factors for HCC recurrence were alpha‐fetoprotein level, tumor size, microvascular invasion, gross major vessel invasion, bilateral tumor distribution, and histologic differentiation in the LDLT group on univariate analysis, and tumor size, gross major vessel invasion, and histologic differentiation on multivariate analysis. Milan criteria were met in 70.4%: Their 3‐YSR was 89.9% after CDLT and 91.4% after LDLT with exclusion of perioperative mortality. University of California San Francisco criteria were met in 77.7%: Their 3‐YSR was 88.1% after CDLT and 90.6% after LDLT. In conclusion, we think that currently available selection criteria for HCC patients can be applicable to LDLT without change of prognostic power. (Liver Transpl 2005;11:1265–1272.)

Therapeutic Efficacy of Transcatheter Arterial Chemoembolization as Compared With Hepatic Resection in Hepatocellular Carcinoma Patients With Compensated Liver Function in a Hepatitis B Virus–Endemic Area: A Prospective Cohort Study

PURPOSEnIdentifying a special subgroup of hepatocellular carcinoma (HCC) patients who may benefit from transcatheter arterial chemoembolization (TACE) when compared with the standard treatment of hepatic resection (HR) warrants research in Asian countries.nnnPATIENTS AND METHODSnFrom January 1993 to December 1994, 182 patients with operable HCC (Child-Pugh class A and International Union Against Cancer [UICC] stage T1-3N0M0) were enrolled. After initial TACE and lipiodol computed tomography, 91 received HR and 91, who refused the operation, received repeated sessions of TACE. After stratification according to the tumor stage (UICC and Cancer of the Liver Italian Program [CLIP]) and lipiodol retention pattern, the survival rates of the two treatment groups were compared. The median follow-up period was 83 months.nnnRESULTSnAs of December 31, 2000, 48 patients who underwent HR and 68 patients who underwent TACE had died. In a subgroup analysis according to tumor stage, the HR group survival rate was significantly higher than the TACE group in both UICC T1-2N0M0 (P =.0058) and CLIP 0 (P =.0027) subgroups. However, there was no significant difference in either UICC T3N0M0 (P =.7512) or CLIP 1-2 (P =.5366) subgroups. Even in patients with UICC T1-2N0M0 HCC, when lipiodol was compactly retained, the survival rate of the HR group was comparable to that of the TACE group (P =.0596).nnnCONCLUSIONnTACE proved to be as effective as HR in the subpopulations with UICC T3N0M0 or CLIP 1-2 HCC and adequate liver function, and even with UICC T1-2N0M0 HCC when lipiodol was compactly retained in the tumor. In such cases, the choice of treatment modality between TACE and HR may be left to the patients preference.

Attempted treatment of factor H deficiency by liver transplantation

Complement factor H (FH) deficiency is one of the causes of atypical hemolytic uremic syndrome (HUS). Most patients with FH deficiency associated HUS progress to end-stage renal disease despite plasma therapy. Moreover, the disease invariably recurs in the graft kidney and causes graft failure. We confirmed FH deficiency in a 30-month-old boy with recurrent HUS of 2xa0years duration, and attempted an auxiliary partial orthotopic liver transplantation (APOLT) to overcome the sustained intractable dependency on plasma therapy. APOLT restored the plasma FH level, without HUS recurrence, for 7xa0months. However, thereafter he suffered from serious infectious complications associated with immunosuppression and finally died 11xa0months after APOLT. In conclusion, although APOLT showed clinical and laboratory improvement for some period in this patient, the final fatal outcome suggests that liver transplantation should be cautiously applied to patients with HUS associated with FH deficiency.

Laparoscopy-Assisted Donor Right Hepatectomy Using a Hand Port System Preserving the Middle Hepatic Vein Branches

BackgroundThis report reviews our experience with a modified right hepatectomy (MRH) using laparoscopic or laparoscopy-assisted techniques preserving the middle hepatic vein (MHV) branches in living donor liver transplantation.MethodsNine female donors (17–36xa0years) underwent a laparoscopic MRH under pneumoperitoneum (L-MRH; nxa0=xa02) or a laparoscopy-assisted MRH (LA-MRH; nxa0=xa07) with a hand port device. The donors for this minimally invasive surgery were volunteers with the willingness to undergo laparoscopic surgery and recipients who were not in urgent need of transplantation. Mobilization of the right liver was performed under pneumoperitoneum in all cases. Hilar dissection and parenchymal transection were performed under pneumoperitonuem (nxa0=xa02) or with a mini-laparotomy incision (nxa0=xa07) using an ultrasonic aspirator without the Pringle maneuver. The major MHV branches (>5xa0mm) were preserved using Hem-o-lock clips. The graft was extracted through the site of the hand port device or the mini-laparotomy. On the back table, the MHV branches were reconstructed with an artificial vascular graft.ResultsThere were no open conversions, and the graft was transplanted without any problem in every case. The operative time for the donors was 765xa0min and 898xa0min in the L-MRH patients, and it ranged from 310 to 575xa0min for the laparoscopy-assisted surgery. None of the donors required transfusion or reoperation; they were discharged on postoperative day 8–14 with normal liver function. A major complication occurred in one donor; fluid collection along the liver resection margin with fever was treated and resolved after percutaneous drainage.ConclusionsA right hepatectomy preserving the MHV or its branches by minimally invasive techniques including total laparoscopic surgery was technically feasible. However, further refinements of the procedure are required prior to wide clinical application.

Platelet Transfusion can be Related to Liver Regeneration After Living Donor Liver Transplantation

BackgroundAlthough liver regeneration is a fundamental aspect of living donor liver transplantation (LDLT), the factors that affect liver regeneration during the early post-transplantation period have not been thoroughly investigated. Recently it was suggested that platelets contribute to liver regeneration. The aim of the present study was to identify the major factors that affect liver graft regeneration during the early post-transplantation period.Materials and methodsEighty-seven right liver grafted, adult-to-adult LDLT patients were retrospectively analyzed. Liver regeneration was assessed by volumetry from computed tomographic (CT) scans obtained between the 9th and 11th postoperative days. The authors investigated relationships between clinical variables and liver graft regeneration rates, and they conducted multiple regression analysis on factors found to be significant by univariate analysis.ResultsMean graft weight at operation was 722.9xa0±xa0109.7xa0g, and mean graft volume assessed by follow-up CT was 1,042.2xa0±xa0155.6xa0ml, reflecting a mean liver graft regeneration of 45.9xa0±xa022.3%. The graft regeneration was found to correlate inversely with graft-to-recipient weight ratio (GRWR, rxa0=xa0−0.406, pxa0<xa00.001) and directly with portal flow velocity (cm/s; rxa0=xa00.307; pxa0=xa00.004) and splenic index (cm3; rxa0=xa00.282; pxa0=xa00.009). Moreover, the total amount (units) of platelets transfused was found to be significantly associated with graft regeneration (rxa0=xa00.293; pxa0=xa0−.006). Stepwise regression analysis showed that GRWR (βxa0=xa0−33.124; pxa0=xa00.001), total amount of platelets transfused (βxa0=xa00.771; pxa0=xa00.012), and splenic index (βxa0=xa0−0.010; pxa0=xa00.049) were independently associated with graft regeneration.ConclusionsThe results of the present study suggest that platelets play a significant role in human liver regeneration after LDLT.

Assessment of Hepatic Arterial Anatomy in Keeping with Preservation of the Vasculature While Performing Pancreatoduodenectomy: An Opinion

BackgroundPancreatic surgeons often must make decisions regarding hepatic artery (HA) resection while performing a pancreatoduodenectomy (PD). The purpose of this report was to review and summarize HA resection experience with a focus on vascular preservation during PD and to develop a useful guideline for pancreatic surgeons in dealing with these needs.MethodsWe reviewed 1324 cases that had available computed tomographic and angiographic findings and summarized the problematic HA variations encountered in PD. In reviewing our PD series (nxa0=xa0254), we have created a set of guidelines that enable a pragmatic approach to the unique variations in HA and the risks of cancer invasion.ResultsChallenging HA variations during PD were found in 20.1% of the cases and included the common HA arising from the superior mesenteric artery (SMA) (2.34%), a replaced right HA (RHA) from the SMA (9.82%), an RHA or left HA from the gastroduodenal artery (0.97%), and the right anterior or right posterior HA from the SMA (1.06%), among others. In our PD series, the problematic HAs (15.8%) were preserved, except for a single case (0.4%) in which PD involved en bloc resection of the RHA from the SMA due to a cancerous invasion and without right hemihepatectomy.ConclusionsSurgeons should have knowledge of the anatomically variable vasculature of the HA when planning for PD. Preoperative imaging studies can aid and should be performed in anticipation of the potential HA variations during PD.

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.

Preoperative evaluation of the hepatic vascular anatomy in living liver donors: comparison of CT angiography and MR angiography

To compare the diagnostic performance of CT angiography (CTA) and MR angiography (MRA) for preoperative hepatic vascular evaluation in living liver donors.

Combinational effect of intestinal and hepatic CYP3A5 genotypes on tacrolimus pharmacokinetics in recipients of living donor liver transplantation.

Background For living donor liver transplantation, the genetic association of CYP3A5 genotype of recipient’s native intestine and donor’s liver allograft with tacrolimus pharmacokinetics has not been explained completely considering liver regeneration time. The goal of the study was to investigate the longitudinal effects of recipient-donor combinational CYP3A5 genotypes on tacrolimus dose-normalized concentration (C/D ratio) in blood. Methods Tacrolimus blood concentrations were measured for 58 Korean adult living donor liver transplant recipients on tacrolimus-based immunosuppressants during 4 years of follow-up. CYP3A5 was genotyped for both recipient and donor, and the recipient-donor combinational genetic effect on tacrolimus C/D ratios were evaluated as a function of time after adjusting for covariates including demographics and clinical variables. Results CYP3A5 expresser recipients grafted from CYP3A5 expresser donors consistently had the least C/D ratio throughout the entire study period, whereas CYP3A5 expresser recipients grafted from CYP3A5 nonexpresser donors had an intermediate, and CYP3A5 nonexpresser recipients grafted from CYP3A5 nonexpresser donors had the largest C/D ratio (all P < 0.01). The CYP3A5 nonexpresser recipients grafted from CYP3A5 expresser donors showed a significant decrease from the largest to the intermediate in C/D ratio for the first month. Conclusions CYP3A5 genotypes of both recipient and donor were important factors influencing pharmacokinetic variability of tacrolimus. The recipient-donor combinational genetic effect on C/D ratio changed over time after transplantation.

Current role of surgery in treatment of early stage hepatocellular carcinoma: resection versus liver transplantation.

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and is most commonly associated with hepatitis B infection in Korea. Although liver resection is regarded as a potentially curative treatment option, it is only feasible in less than 20% of patients. The reason for this is that HCC arises in cirrhotic livers and is often multicentric. Liver transplantation (LT) which could be used in the treatment both of the tumor and background liver seems to be a rational approach for early stage patients with decompensated liver cirrhosis. Current good selection criteria of LT for HCC are the Milan criteria: 1 HCC nodule ≤5 cm in diameter or 3 nodules ≤3 cm. By restricting LT to patients within the Milan criteria, the 4-year disease-free survival rate was more than 80%, which is comparable to that of a transplant candidate without HCC. However, there are serious limitations for the wider application of LT for HCC: (1) organ shortage, (2) risk to a live donor, (3) high cost, and (4) lifelong immunosuppression. For this reason, for a patient with early stage HCC and with Child A cirrhosis in whom partial hepatectomy is possible, the choice of primary treatment with curative intent is still under debate.