Tae Jin Lim

Benefit of systematic segmentectomy of the hepatocellular carcinoma: revisiting the dye injection method for various portal vein branches.

Background: Systematic segmentectomy is useful in treating small hepatocellular carcinoma in the cirrhotic liver. However, accomplishment of an exact systematic segmentectomy still remains a challenging procedure because of the variable anatomy of portal branches. We evaluated the usefulness of the dye injection method for systematic segmentectomy, which focuses on the various patterns of portal vein (PV) branches feeding the tumor. Methods: From January 2001 to May 2011, systematic segmentectomy by the dye injection method was performed in 70 patients. We evaluated the efficiency of systematic segmentectomy by ultrasonogram-guided dye injection into the portal branches that feed the tumor-bearing segments. The type of tumor-feeding PV branch, perioperative outcome, and survival rates were analyzed retrospectively. Results: There were variations in the PV branches that fed the masses in 70 patients in whom the dye injection method for anatomical segmentectomy was tried. Forty masses (54.8%) were fed by a single main PV branch (type 1), 17 masses (23.3%) by a couple of PV branches (type 2), and 11 masses (15.1%) were supplied partially by single PV branch (type 3). In 5 patients (7.1%), masses were supplied by several small distributed PVs (type 4). For types 1 and 2, the tumor-bearing segments were resected anatomically with the help of staining; type 3 was partially stained and as the opposite side was not discrete, it was demarcated through counterstaining; and in type 4, dye injection could not be performed. Anatomical systematic segmentectomy was obtained in types 1 to 3; however, nonanatomical resection was inevitable for type 4. The 3- and 5-year overall survival rates were 80.5% and 67.2%, respectively, and the 3- and 5-year disease-free survival rates were 61.5% and 42.5%, respectively. The anatomical segmentectomy group showed better overall and disease-free survival than the nonanatomical group, even though it is not significant statistically. Conclusion: Systematic segmentectomy by the dye injection method overcomes the variation in PV tributaries in the segments and can be done according to the natural branching pattern of PVs.

Optimal cycle of intermittent portal triad clamping during liver resection in the murine liver

We designed this experimental study to determine the optimal cycle for intermittent inflow occlusion during liver resection. A cycle of intermittent clamping (IC) for 15 minutes of ischemia followed by reperfusion for 5 minutes during liver resection is currently the most popular protocol used by experienced liver centers. As each period of reperfusion is associated with bleeding, longer periods of clamping would be advantageous. However, the longest safe duration of successive ischemia is unknown. Three groups of mice were subjected to a total liver ischemic period for 90 minutes; 2 groups underwent IC for 15 or 30 minutes, respectively, followed by 5 minutes of reperfusion, while the control group was subjected to continuous inflow occlusion only. The degree of tissue injury was assessed using biochemical and histological markers, as well as animal survival. While serious injury was observed in the continuous clamping group, both IC groups were associated with minimal injury, including lesser degrees of apoptosis and necrosis. All animals survived in the IC groups, while all animals died following 90 minutes of continuous inflow occlusion. In conclusion, intermittent portal pedicle clamping with 15‐ or 30‐minute cycles is highly protective. A period of 30 minutes clamping should be preferred, since this would decrease the amount of blood loss associated with each cycle. This data should be confirmed in humans, and may represent a change in the current practice of hepatic surgery. (Liver Transpl 2004;10:794–801.)

Risk factors for early recurrence after surgical resection for hepatocellular carcinoma

BACKGROUND/AIMS Early recurrence (ER) after liver resection is one of the most important factors impacting the prognosis and survival of patients with hepatocellular carcinoma (HCC). This study aimed to identify the factors associated with ER after curative hepatic resection for HCC. METHODS From the July 2000 to July 2006, 144 patients underwent hepatic resection for HCC at a single institution. After excluding those with ruptured HCC, combined or mixed HCC, and who died during admission, 116 patients were analyzed. Patients with ER (defined as within 1 year) were compared with those who remained free of disease for more than 1 year. Various clinical characteristics including tumor and operative factors were evaluated to determine the factors predicting postoperative ER using univariate and multivariate analyses. RESULTS ER occurred in 51 patients (44%). In the univariate analysis, tumor size (P=0.001), microvascular invasion (P=0.003), portal vein invasion (P=0.001), TNM stage (P=0.010), serum levels of alpha-fetoprotein (AFP) (P=0.002) and aspartate aminotransferase (AST) (P=0.011), and operative time (P=0.033) were significantly associated with ER. AFP and AST were the independent predictors of ER in the multivariate analysis (P<0.05). CONCLUSIONS Preoperative serum AFP and AST levels were the independent risk factors for ER after surgical resection for HCC. Close postoperative surveillance is recommended for early detection of recurrence and additional treatments in patients with these factors.

The impact of old age on surgical outcomes after pancreaticoduodenectomy for distal bile duct cancer.

Backgrounds/Aims To compare surgical results and survival of two groups of patients, age ≥70 vs. age <70, who underwent pancreaticoduodenectomy and to identify the safety of this procedure for elderly patients for the treatment of distal common bile duct (CBD) cancer. Methods Between January 2003 and December 2009, 55 patients who underwent pancreaticoduodenectomy for the treatment of distal CBD cancer at Keimyung University Dong San Medical Center were enrolled in our study. Results Of 55 patients, 28 were male and 27 female. Nineteen were over 70 years old (older group) and 36 were below 70 years (younger group). The mean ages of the two groups of patients were 73.5 years and 60.5 years respectively. Although patients of the older group had significantly more comorbid diseases, perioperative results including operation time, amount of intraoperative bleeding, duration of postoperative hospital stay and postoperative complications were not significantly different. A higher level (more than 5 mg/dl) of preoperative initial bilirubin showed significant correlations with operative morbidity by univariate analysis, and age was not an independent risk factor of operative morbidity. Overall 5 year survival of older and younger groups were 45.9% and 39.5% respectively (p=0.671) and disease-free 5-year survival were 31.7% and 31.1%, respectively (p=0.942). Conclusions Surgical outcomes of elderly patients were similar to those of younger patients, despite a higher incidence of comorbid disease. This results shows that pancreaticoduodenectomy can be applied safely to elderly patients.

Laparoscopic Appendectomy is Feasible for the Complicated Appendicitis

We reviewed the results of 339 consecutive appendectomies, including perforated appendicitis, to assess the advantages of the laparoscopic approach for acute appendicitis. Three hundred and eighty-eight patients underwent appendectomy at the Keimyung University Kyungju Dongsan Hospital between March 1994 and June 1996; 339 patients were treated using laparoscopic appendectomy (LA), and 49 patients who were treated with open appendectomy. Special emphasis was given to the results of LA in 27 patients with perforated appendicitis. The mean duration of the operating time for LA was 48.9 minutes. For six patients (1.8%), the procedure was converted to open surgery. Minor complications developed in eight patients (2.4%). There were no complications in the 27 patients with perforated appendicitis. Our experience with LA in perforated appendicitis is limited, but our results show that LA is a safe and acceptable procedure for all forms of acute appendicitis.

Tip for microlaparoscopic cholecystectomy: easy removal of the gallbladder after laparoscopic cholecystectomy using the three-port technique.

The standard laparoscopic cholecystectomy usually requires four trocars: two 10-mm and two 5-mm trocars. With the development of mini-instruments, laparoscopic surgeons have developed the two- or three-port techniques. The selection of the number and size of trocars depends on the surgeons experience and preferences. Removal of the gallbladder is critical in the mini-instrument technique. To remove the gallbladder through the umbilical port, a 5-mm telescope should be inserted through one of the 5-mm ports, or one of the 5-mm trocars should be replaced with an 11-mm trocar by extending the incision. A simple and easy technique was applied to retrieve the gallbladder without changing the telescope or extending the skin incision for the trocar port to 11 mm. When the gallbladder is detached from the liver, the surgeon grasps the neck of the gallbladder via the 5-mm trocar and positions the gallbladder in the 11-mm trocar. While the surgeon keeps the gallbladder in the 11-mm trocar with the grasper held tangentially, the assistant removes the telescope and inserts a straight-toothed grasper to capture the gallbladder neck blindly. Subsequently, the removal of the gallbladder together with the trocar follows the usual technique. We have applied this technique to all our patients with limited or no inflammation of the gallbladder.

Living-Donor Liver Transplant With an Interposition Graft of the Inferior Vena Cava for Hepatocellular Carcinoma: Beyond the Milan Criteria and Within the UCSF Criteria

Living-donor liver transplant for a big hepatocellular carcinoma located in the caudate lobe is challenging owing to dissemination of cancer cells during recipient hepatectomy. We report a case of living-donor liver transplant using the right side of the liver of a living donor combined with inferior vena cava interposition graft after en bloc resection of the liver and retrohepatic inferior vena cava for hepatocellular carcinoma in the caudate lobe. A 50-year-old man with chronic hepatitis B cirrhosis developed hepatocellular carcinoma in the caudate lobe and segment 5. The diameters of the masses were 4.5 cm and 2.5 cm. His model for end-stage liver disease score was 17, and he had a moderate amount of ascites. For the recipient hepatectomy, en bloc resection of the entire liver, including retrohepatic inferior vena cava and reconstruction of inferior vena cava with Dacron graft, were performed. We then performed a transplant of the right lobe taken from the living donor. This technique can be a new alternative curative treatment option for hepatocellular carcinoma located on the hepatocaval confluence or close to the inferior vena cava. We should evaluate the long-term safety for cancer recurrence and infection of an artificial vascular graft in the milieu of immunosuppression after liver transplant.