Sung-Hwa Kang

Pure Laparoscopic Versus Open Right Hepatectomy for Hepatocellular Carcinoma in Patients With Cirrhosis: A Propensity Score Matched Analysis.

Objective: We aimed to describe our experience with pure laparoscopic right hepatectomy (LRH) and to compare its outcomes with those of open right hepatectomy (ORH) in hepatocellular carcinoma (HCC) patients with liver cirrhosis. Background: Laparoscopic liver resection has been reported as a safe and effective approach for the management of liver cancer; however, its outcomes have not been evaluated in a large cohort of HCC patients with liver cirrhosis. Methods: We retrospectively reviewed the medical records of 152 patients who underwent pure LRH (n = 37) or ORH (n = 115) between June 2008 and July 2015 at the Asan Medical Center in Seoul, Korea. We performed 1:1 propensity score matching between the LRH and ORH groups. Subsequently, 33 patients were included in each group. Results: There was no statistically significant difference between the LRH and ORH groups regarding the rate of complications (P = 0.053). However, the mean comprehensive complication index, which accounts for the severity of complications, was significantly lower in the LRH group (0.63 vs 4.42; P = 0.025). There were no significant differences between the LRH and ORH groups regarding 2-year disease-free survival rate or 2-year overall survival rate (P = 0.645 and P = 0.090, respectively). Conclusions: Even in patients with cirrhosis, pure LRH is not less safe than the traditional open approach. The oncological outcomes of HCC were also comparable between the two groups. In selected patients, pure LRH for HCC appears to represent a viable alternative to ORH.

Biliary stricture is the only concern in ABO-incompatible adult living donor liver transplantation in the rituximab era

BACKGROUND & AIMS With the introduction of rituximab prophylaxis, the survival of ABO-incompatible (ABOi) adult living donor liver transplant (ALDLT) has been strikingly improved due to the decreased incidence of antibody-mediated rejection. However, biliary stricture (BS) related to ABO incompatibility remains an unresolved concern. METHODS Excluding 105 dual graft ALDLTs, 1102 ALDLT cases including 142 ABOi recipients were included in this study. The desensitization protocol for overcoming the ABO blood group barrier comprised pretransplant plasma exchange, and rituximab (300-375 mg/m(2) BSA). RESULTS The mean follow-up period was 34.2 ± 15.4 months. The cumulative graft and patient survival rates were comparable in the two groups. The 1- and 3-year BS-free survival rates of ABOi ALDLT were 81.5 and 79.0%, respectively, lower than those of ABOc ALDLT (87.6 and 85.7%, respectively, p=0.022). In the risk factor analysis, diameter of graft bile duct opening <5mm, antecedent acute cellular rejection, and ABO incompatibility were independent risk factors for BS. Diffuse intrahepatic biliary stricture (DIHBS) exclusively occurred in 12 patients (8.5%) receiving ABOi ALDLT. The deaths of 3 patients and 4 cases of re-transplantation were related to DIHBS. Graft and patient survival rates were significantly reduced in ABOi ALDLT recipients with DIHBS. However, we failed to identify any significant risk factors for DIHBS. CONCLUSIONS The incidence of BS in ABOi ALDLT is higher than in ABOc, mainly due to the fact of DIHBS which significantly affected survival outcomes. To predict and prevent DIHBS, we need further studies to identify significant risk factors.

Initial Outcomes of Pure Laparoscopic Living Donor Right Hepatectomy in an Experienced Adult Living Donor Liver Transplant Center

Background Only a limited number of centers have performed laparoscopic living donor hepatectomy to date. In particular, laparoscopic right hepatectomy is rarely performed because the procedure can only be performed by surgeons with significant experience in both laparoscopic liver surgery and liver transplantation with living donor liver grafts. Methods Between November 2014 and February 2015, in a pure laparoscopic approach program for living right lobe donors at Asan Medical Center, 92 living donors underwent right hepatectomy for adult living donor liver transplantation. Among these, 3 pure laparoscopic living donor right hepatectomies were performed in 3 young female donors. Results The intraoperative and postoperative courses for all 3 donors and recipients were uneventful without any complications. Laparoscopic living donor hepatectomy has definite advantages over conventional open surgery, including decreased wound morbidity and faster recovery. Conclusions According to the data of the present report, pure laparoscopic living donor right hepatectomy in properly selected living donors (only 4% of potential donors in this cohort) appears to be a safe and feasible procedure in adult living donor liver transplantation.

Section 15. A desensitizing protocol without local graft infusion therapy and splenectomy is a safe and effective method in ABO-incompatible adult LDLT.

Background The use of rituximab (Rit) to prevent antibody-mediated rejection (AMR) of ABO-incompatible (ABOi) adult living donor liver transplants (ALDLTs) has raised questions about the role of local graft infusion therapy (LGIT) and splenectomy (SPN); however, they are still regarded as essential components of the desensitization (DSZ) protocol. Methods The DSZ protocol consisted of plasma exchange and Rit. None of the patients underwent SPN. The patients were divided into two groups. The patients in Group I (n=20) received LGIT via the hepatic artery or portal vein. The patients in Group II (n=100) did not receive LGIT. Results One hundred twenty ABOi ALDLTs were performed from November 2008 to June 2012, and there was only one case of operative mortality (0.8%). There was no significant difference in the 3-year patient survival rates between patients receiving ABO-compatible and ABOi ALDLT (88.8% vs. 94.8%; P=0.11). LGIT catheter-related complications occurred in six patients (30.0%). There was no statistically significant difference in the 3-year patient survival rates between the groups (90.0% vs. 95.0%; P=0.26). One patient in Group 1 (0.8%) experienced AMR. Diffuse intrahepatic biliary stricture occurred in two patients (10.0%) in Group I and in five patients (5.0%) in Group II, although the difference was not statistically significant (P=0.11). The incidence of biliary stricture was similar in both groups (P=0.06), but the incidence of infection was significantly higher in Group I (P=0.03). Conclusion The DSZ protocol without LGIT and splenectomy is a safe and effective method of attaining a successful outcome of ABOi ALDLT.

Surgical outcomes following laparoscopic major hepatectomy for various liver diseases

Abstract The aim of the study was to report surgical outcomes (efficacy and safety) of laparoscopic major hepatectomy for various liver diseases. Although the number of laparoscopic liver resections has increased, expansion of laparoscopic major hepatic resection remains limited, mainly owing to the technical difficulties for the procedure as compared to open surgery. We describe our experiences with laparoscopic major hepatectomy for various liver diseases. We retrospectively reviewed the medical records of 192 patients who underwent laparoscopic major hepatectomy between October 2007 and March 2015 at Asan Medical Center, Korea. The mean age of the patients was 54 ± 11.6 years, and their mean body mass index was 23.5 kg/m2. The most common preoperative diagnosis was hepatocellular carcinoma (n = 82, 42.7%), followed by intrahepatic duct stones (n = 51, 26.6%). We performed 108 left hepatectomies, 55 right hepatectomies, 18 right posterior sectionectomies, 6 right anterior sectionectomies, 2 central bisectionectomies, and 3 donor right hepatectomies. The conversion rate was 1.6% (3 cases) due to bleeding, bile leakage, and uncontrolled hypercapnea during the operation. The mean operation time was 272 ± 80.2 minutes, and the mean estimated blood loss was 300.4 ± 252.2 mL. The mean postoperative hospital stay was 9.8 days. All resection margins were tumor-free in cases of malignant tumors. The morbidity rate was 3.1% (n = 6), including for case of biliary stricture. There were no deaths. Laparoscopic major hepatectomy, including donor hepatectomy, is a safe and feasible option for various liver diseases when careful selection criteria are used by a surgeon experienced with the relevant surgical techniques.

Prevalence analysis of de novo hepatic steatosis following pylorus-preserving pancreaticoduodenectomy.

Background: Prevalence of hepatic steatosis following pylorus-preserving pancreaticoduodenectomy (PPPD) is high. This study intended to reveal the prevalence and patterns of de novo hepatic steatosis following PPPD. Methods: We investigated postoperative de novo hepatic steatosis following PPPD (n = 101) with a control group of bile duct resection (BDR) (n = 54). Results: At postoperative 1 year, hepatic steatosis occurred in 21 of 82 patients (25.6%) of PPPD group and in 2 of 47 patients (4.3%) of BDR group (p = 0.001). Thereafter, at 2 to 5 years, a high prevalence of hepatic steatosis persisted in the PPPD group, but no further occurrence developed in BDR group. Once steatosis developed, it persisted until the end of the study period or patient death. Five-year cumulative incidence of hepatic steatosis was 26.7% in the PPPD group and 3.7% in BDR group (p < 0.001). Univariate analyses showed that patient sex, age, body mass index, blood lipid profile, recurrence of tumor, and diabetes did not have significant influence on the development of hepatic steatosis following PPPD. Conclusions: De novo hepatic steatosis may develop in a not negligible proportion of patients undergone PPPD. Multicenter studies with a high number of patients are needed to elucidate its pathogenesis and to find effective treatment for pancreaticoduodenectomy-associated hepatic steatosis. i 2014 S. Karger AG, Basel

A comparative study regarding the effect of an intraperitoneal anti-adhesive agent application in left-liver living donors

Backgrounds/Aims After left-sided hepatectomy due to a living donor, the stomach can become adhered to the hepatic cut surface. An unwanted gastric stasis can occur. For prevention of such gastric adhesion and laparotomy-associated adhesive ileus, some anti-adhesive agents have been developed for intra-abdominal application. The purpose of this study is to evaluate the effect of an intraperitoneal anti-adhesive agent application compared with a historical control group. Methods The study group consisted of 220 consecutive living donors who donated a left-liver graft during the time period between January 2006 and December 2011. The anti-adhesive agent which was used was composed of sodium hyaluronate and sodium carboxymethyl cellulose. The historical control group which used no anti-adhesive agent included 220 consecutive left-liver donors during the time period between January 1998 and December 2004. Results An overt gastric stasis which required fasting was observed in 5 subjects (2.3%) in the study group and in 7 subjects (3.2%) in the control group (p=0.77). An additional work-up to determine gastric stasis or prolonged ileus was performed in 17 (7.7%) and 22 (10%) donors, respectively (p=0.51). Only one donor in the control group underwent a laparotomy for an intestinal obstruction. No clinical factors such as patient age, sex, body mass index, remnant right liver proportion, shape of skin incision, and duration of surgery were significant risk factors of gastric stasis or prolonged ileus. No harmful side-effects of the anti-adhesive agent were identified. Conclusions As a result of this study, the application of an anti-adhesive agent could not be proved as to be effective for prevention of gastric stasis and postoperative ileus. A further randomized and controlled study will be required to demonstrate the real benefits of an anti-adhesive application in left-liver living donors.

Post-Transplant Assessment of Consciousness in Acute-on-Chronic Liver Failure Patients Undergoing Liver Transplantation Using Bispectral Index Monitoring

PURPOSE Deterioration of consciousness is a critical situation for liver transplantation (OLT) recipients. The bispectral (BIS) index based on electroencephalographic parameters, is primarily used to monitor the depth of unconsciousness. The present study sought to assess the usefulness of posttransplant BIS index to monitor acute-on-chronic liver failure patients. METHODS This 1-year retrospective study of 28 adult patients with acute-on-chronic liver failure was performed from July 2011 to June 2012, using post-transplant BIS monitoring. RESULTS The mean patient age was 51 ± 8 years. Their mean pretransplant Child-Turcotte-Pugh score was 12.3 ± 1.4, and the mean Model for End-stage Liver Disease score, 36.4 ± 5.9. After OLT, the mean initial Glasgow Coma Scale (GCS) score and BIS index were 3.4 ± 1.7 and 43.5 ± 9.1, respectively. After 6 hours the mean GCS and BIS values rose to 8.6 ± 4.0 and 52.4 ± 10.3 and after 12 hours to 9.7 ± 3.4 and 61.3 ± 15.7 respectively. Eye opening in response to a voice occurred at a mean of 8.9 ± 6.7 hours after arrival in the intensive care unit regardless of graft function. The mean GCS and BIS values were 10.6 ± 2.8 and 69.1 ± 13.5, respectively. The endotracheal tube was removed after a median of 140 hours; 9 patients required a tracheostomy. Among them 2 died within the first 3 months after OLT. CONCLUSIONS BIS monitoring is a noninvasive, simple, easy-to-interpret method to measure consciousness among patients intubated with an endotracheal tube.

Conjoined unification venoplasty for graft double portal vein branches as a modification of autologous Y‐graft interposition

Anomalous portal vein (PV) branching of the right liver is encountered in a considerable proportion of living liver donors. This type of liver anomaly has often led to double PV orifices at the right liver graft. Historically, several reconstruction methods, including direct unification venoplasty, have been attempted for these double PVs, with an autologous portal Y-graft interposition being regarded as the standard procedure for living donor liver transplantation (LDLT) because it has shown acceptably low rates of early PV stenosis with excellent long-term patency. However, autologous portal Y-graft interposition may occasionally be technically demanding because of its low tolerance of alignment error between the graft and recipient PVs. In practice, inadequate alignment of the PV anastomosis makes the right posterior section (RPS) PV branch excessively redundant, and this can result in buckling deformity and functional stenosis of the RPS PV branch. To ensure hemodynamically compliant reconstruction of the right liver graft with double PV orifices, we developed a refined technique consisting of conjoined unification venoplasty as a modification of conventional Y-graft interposition. Our previous reports on the patency of portal Ygraft interposition revealed that 5 of 79 patients (6.3%) required early PV stenting within the first week because of anastomotic stenosis (n 5 3) or buckling deformity (n 5 2). To improve the outcome, the surgical technique was modified, and this was described in detail previously. Despite these technical refinements, functional stenosis of the RPS PV branch still occurred sporadically (n 5 2), with these patients requiring intraoperative PV stenting. An analysis of the mechanisms underlying PV stenosis in the 7 patients who underwent early PV stenting found that a small diameter or long extrahepatic stump of the RPS PV branch was responsible for buckling deformity when conventional portal Y-graft interposition was performed. The hemodynamic effects of a graft RPS PV with a small diameter or a long extrahepatic stump were assessed by computational simulation analysis using fluid dynamics software (900 node version; ADINA R&D, Watertown, MA). Several simulation models were developed to assess the hemodynamic compliance with respect to the alignment error of the PV anastomosis. A conjoined unification venoplasty model similar to making a potbelly-like confluence portion was found to be most tolerant of PV alignment errors (Fig. 1). The technical feasibility of this computational model was assessed by the construction of a physical model with flexible, heat-shrinkable polyolefin tubes. The vessel diameter was reduced through the blowing of hot air over the tubes, which were cut according to the shapes designed in the simulation models. These artificial vessels were also sutured to confirm their technical feasibility. The study protocol, including a retrospective clinical review, computational simulation, and clinical application, was approved by the institutional review board of our institution. The surgical technique for newly developed conjoined unification venoplasty was optimized before clinical application. This technique consists of the placement of a small vein unification patch between 2 sectional PV branches, which is followed by coverage with a crutch-opened, autologous PV Y-graft. In practice, a similar surgical technique has been seldom used when the condition of the autologous PV Y-graft was not optimal (eg, excessive size discrepancy or thrombosis of the sectional PV orifices), and

Tailored long-term immunosuppressive regimen for adult liver transplant recipients with hepatocellular carcinoma

Backgrounds/Aims There are few guidelines for tailored immunosuppressive regimens for liver transplantation (LT) recipients with hepatocellular carcinoma (HCC). To establish long-term immunosuppressive regimens suitable for Korean adult LT recipients, we analyzed those that were currently in use at a single high-volume institution. Methods This cross-sectional study comprises three parts including review of the immunosuppressive regimens used to manage 2,147 adult LT outpatients, review of LT recipients who were diagnosed of HCC at LT, and review of LT recipients who suffered from HCC recurrence. Results In 1,000 adult LT recipients who were living more than 5 years with no adverse events, 916 received a calcineurin inhibitor (CNI)-based therapy (CNI only in 520; CNI with mycophenolate mofetil [MMF] in 396) and 84 were receiving an MMF-based therapy (MMF only in 45; MMF with minimal CNI in 39). Tacrolimus was preferred over cyclosporine for both monotherapy and combination therapy along the passage of posttransplant period. There was no difference in selection of immunosuppressants, target blood concentration, and rate of combination therapy between LT recipients with and without HCC, except for the first 1 year. Sirolimus-based regimens were applied in 21 patients who showed HCC recurrence. Sorafenib was often used after conversion to sirolimus. Conclusions Tailored immunosuppressive regimen covering the long-term posttransplant period should be established after consideration of individualized patient profiles including HCC.