Seung Duk Lee

(18) F-FDG-PET/CT predicts early tumor recurrence in living donor liver transplantation for hepatocellular carcinoma.

The prognosis including 18F‐fluorodeoxyglucose positron emission tomography/computed tomography (18F‐FDG‐PET/CT) for the early recurrence for hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT) was not well established. Consecutive patients who underwent 18F‐FDG‐PET/CT and subsequent LDLT for HCC from March 2005 to June 2011 were enrolled. The 191 patients with a median follow‐up of 26.1 months were evaluated. There were 20 patients (10.5%) with early recurrence (≤6 months), 18 patients (9.4%) with late recurrence (>6 months), and 153 patients (80.1%) with no recurrence. Fifty‐five patients (28.8%) displayed increased PET/CT tumor uptake. Three‐year overall and disease‐free survival for PET/CT‐positive patients were 65.5% and 57.1%, respectively, while PET/CT‐negative patients showed respective values of 89.8% and 86.8% (P = 0.001 vs. P < 0.001). Tumor variables associated with PET/CT‐positive finding were preoperative AFP level, Milan, UCSF criteria, maximum tumor size, total tumor size, differentiation, vascular invasion, and serosal invasion. PET/CT‐positive status was identified as an independent prognostic factor for disease‐free survival influencing early recurrence in multivariable analysis (HR 3.945, 95% CI 1.196–13.016, P = 0.024). 18F‐FDG‐PET/CT is an independent and significant predictor of early tumor recurrence in LDLT for HCC.

Graft-to-recipient weight ratio lower to 0.7% is safe without portal pressure modulation in right-lobe living donor liver transplantation with favorable conditions.

BACKGROUND The low graft-to-recipient weight ratio (GRWR) in adult-to-adult living donor liver transplantation (LDLT) is one of the major risk factors affecting graft survival. The goal of this study was to evaluate whether the lower limit of the GRWR can be safely reduced without portal pressure modulation in right-lobe LDLT. METHODS From 2005 to 2011, 317 consecutive patients from a single institute underwent LDLT with right-lobe grafts without portal pressure modulation. Of these, 23 had a GRWR of less than 0.7% (group A), 27 had a GRWR of ≥0.7%, <0.8% (group B), and 267 had a GRWR of more than and equal to 0.8% (group C). Medical records, including recipient, donor, operation factors, laboratory findings and complications were reviewed retrospectively. RESULTS The baseline demographics showed low model for end-stage liver disease score (mean 16.3+/-8.9) and high percentage of hepatocellular carcinoma (231 patients, 72.9%). Three groups by GRWR demonstrated similar characteristics except recipient body mass index and donor gender. For small-for-size syndrome, there were 3 (13.0%) in group A, 1 (3.7%) in group B, and 2 patients (0.7%) in group C (P<0.001). Hepatic artery thrombosis was more frequently observed in group A than in groups B and C (8.7% vs 3.7% vs 1.9%, P=0.047). However, among the three groups, graft survival rates at 1 year (100% vs 96.3% vs 93.6%) and 3 years (91.7% vs 73.2% vs 88.1%) were not different (P=0.539). In laboratory measurements, there was no group difference in total bilirubin and albumin. However, prothrombin time was longer in group A within postoperative 1 week and platelet count was lower in groups A and B within postoperative 1 month. CONCLUSION A GRWR lower to 0.7% is safe and does not need to modulate portal pressure in adult-to-adult LDLT using the right-lobe in favorable conditions including low model for end-stage liver disease score.

ABO-incompatible living donor liver transplantation without graft local infusion and splenectomy

BACKGROUND Graft local infusion and splenectomy in ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) are associated with high rates of operative complications. METHODS Consecutive ABO-I LDLT patients treated at the National Cancer Centre between January 2012 and February 2013 were identified. The protocol for ABO-I LDLT at the study centre included the administration of rituximab (300 mg/m(2)) at 2 weeks preoperatively, followed by plasma exchanges (target isoagglutinin titre: ≤ 1:8), basiliximab (20 mg on the day of surgery and on postoperative day 4), and i.v. immunoglobulin (0.8 g/kg on postoperative days 1 and 4) without graft local infusion or splenectomy. RESULTS Fifteen patients (11 men and four women) who underwent transplantation for liver cirrhosis (n = 3) or hepatocellular carcinoma (n = 12) were identified. These included 13 patients with hepatitis B virus infection, one with hepatitis C virus infection and one with alcoholic cirrhosis. The mean age, mean Model for End-stage Liver Disease (MELD) score and mean graft-to-recipient weight ratio (GRWR) of these patients was 51.8 years, 11.5 and 0.84, respectively. The median isoagglutinin titre before plasma exchange was 1:32 (range: 1:4 to 1:256). There were no hyperacute or antibody-mediated rejections. No bacterial or fungal infections were observed. Complications included herpes zoster viral infection in one patient, postoperative bleeding in one patient and extrahepatic biliary stricture in three patients. CONCLUSIONS This simplified ABO-I LDLT protocol showed good graft outcomes without immunologic failure or serious infections.

Surgical outcome of pancreatic cancer using radical antegrade modular pancreatosplenectomy procedure

AIM To evaluate the surgical outcomes following radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic cancer. METHODS Twenty-four patients underwent RAMPS with curative intent between January 2005 and June 2009 at the National Cancer Center, South Korea. Clinicopathologic data, including age, sex, operative findings, pathologic results, adjuvant therapy, postoperative clinical course and follow-up data were retrospectively collected and analyzed for this study. RESULTS Twenty-one patients (87.5%) underwent distal pancreatectomy and 3 patients (12.5%) underwent total pancreatectomy using RAMPS. Nine patients (37.5%) underwent combined vessel resection, including 8 superior mesenteric-portal vein resections and 1 celiac axis resection. Two patients (8.3%) underwent combined resection of other organs, including the colon, stomach or duodenum. Negative tangential margins were achieved in 22 patients (91.7%). The mean tumor diameter for all patients was 4.09 ± 2.15 cm. The 2 patients with positive margins had a mean diameter of 7.25 cm. The mean number of retrieved lymph nodes was 20.92 ± 11.24 and the node positivity rate was 70.8%. The median survival of the 24 patients was 18.23 ± 6.02 mo. Patients with negative margins had a median survival of 21.80 ± 5.30 mo and those with positive margins had a median survival of 6.47 mo (P = 0.021). Nine patients (37.5%) had postoperative complications, but there were no postoperative mortalities. Pancreatic fistula occurred in 4 patients (16.7%): 2 patients had a grade A fistula and 2 had a grade B fistula. On univariate analysis, histologic grade, positive tangential margin, pancreatic fistula and adjuvant therapy were significant prognostic factors for survival. CONCLUSION RAMPS is a feasible procedure for achieving negative tangential margins in patients with carcinoma of the body and tail of the pancreas.

Solid serous cystic neoplasm of the pancreas with invasive growth

A 56-year-old man visited our hospital for a pancreatic mass which was found incidentally during routine medical check-up. He had no underlying diseases and denied smoking, alcohol or familial history of malignancies. Furthermore, no symptoms or abnormalities were observed on physical examination. Laboratory tests revealed no abnormal findings. Tumor markers, including CEA and CA 19-9, were normal. An arterial-phase abdominal computed tomography (CT) scan revealed a 2.1 cm enhancing solid mass abutting the splenic vein in the tail of the pancreas (Fig. 1a, arrow). The tumor remained enhanced on a portal phase of CT (Fig. 1b). Neuroendocrine tumor of the pancreas was strongly suspected with this radiologic finding. Laparoscopic distal pancreatectomy was performed using a four-trocar incision. Gross pathology demonstrated a 2.5 9 2.0 9 1.3 cm solid mass in the pancreatic tail, which was yellow– whitish and firm, with somewhat fuzzy margins. This tumor abutted the pancreatic capsule in the upper margin (Fig. 1c). Histologic examination of the pancreas showed a solid neoplasm composed of compactly arranged glandular structures of cuboidal or polygonal cells, many of which had clear cytoplasms (Fig. 2a). A periodic acid Schiff’s (PAS) stain was weakly positive in the cytoplasm (Fig. 2b). Nuclei were evenly small and round and were darkly stained. Mitoses, cytologic atypia or papillary growth patterns were not identified. Microcystic components were rarely observed. This tumor infiltrated into the surrounding pancreas and peripancreatic soft tissue without capsule, showing frequent islet entrapment and perineural invasion (Fig. 2c). The adjacent splenic vein was invaded by the tumor (Fig. 2d). However, lymph node metastasis was not detected. Immunohistochemical staining revealed that tumor cells were positive for CK7, CK19 and MUC-6, but negative for synaptophysin. The adenomatous area was intervened by a broad band of dense fibrous stroma (Fig. 3a). The stroma showed abundant smooth muscle actin (SMA)-positive myofibroblasts (Fig. 3b). The patient is well 12 months after surgery. Since initially described in 1996, solid SCN has been known as a subtype of serous cystic neoplasms that lack secretory capability and the distinctive cystic architecture of serous cystadenoma [1]. The cytologic and immunohistochemical features of this tumor are indistinguishable from those of serous cystadenoma. All of the 11 reported cases of solid SCN exhibited a well-demarcated margin with the adjacent normal pancreas and vessels [1, 2]. The present case is very unusual in two aspects. First, the tumor has solid and fibrotic components without notable microcysts. Second, unlike the previously reported cases, the tumor shows infiltrative growth in surrounding tissue without circumscription, although it has very small diameter. Conservative treatments can be performed due to the tumor’s benign nature, as seen in previously reported cases. Nevertheless, surgical oncologists should be aware of the possibility of malignant transformation in solid SCN of the pancreas, as in our case. S. D. Lee S.-S. Han (&) E. K. Hong Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 410-769, Republic of Korea e-mail: sshan@ncc.re.kr

Bouveret's syndrome: a case report and a review of the literature.

Bouverets syndrome is a gastric outlet obstruction caused by an impacted gallstone that passes through a cholecysto-gastric or cholecysto-duodenal fistula. An elderly woman visited a local clinic with nausea and abdominal pain. Abdominal computed tomography revealed a stone that was impacted in the duodenal lumen and a fistula between the gallbladder and duodenum. Malignancy could not be excluded due to the mass in the cystic duct showing enhancement and the presence of enlarged lymph nodes on computed tomography, and increased fludeoxyglucose uptake in the cystic duct on positron emission tomography. The patient underwent simultaneous cholecystectomy, segmental duodenectomy and gastro-jejunostomy. Pathological examination exhibited chronic inflammation and no primary cancer of the gallbladder and fistula.

Jejunal varix bleeding with extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy: report of two cases

We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.