Young Dong Yu

Robotic versus laparoscopic liver resection: a comparative study from a single center.

PurposeThe significant advantages of robotic surgery have expanded the scope of surgical procedures that can be performed through minimally invasive techniques. The aim of this study was to compare the perioperative outcomes between robotic and laparoscopic liver surgeries at a single center.MethodsFrom July 2007 to October 2011, a total of 206 patients underwent laparoscopic or robotic liver surgery at the Asan Medical Center, Seoul, Korea. We compared the surgical outcomes between robotic liver surgery and laparoscopic liver surgery during the same period. Only patients who underwent left hemihepatectomy or left lateral sectionectomy were included in this study.ResultsThe robotic group consisted of 13 patients who underwent robotic liver resection including 10 left lateral sectionectomies and three left hemihepatectomies. The laparoscopic group consisted of 17 patients who underwent laparoscopic liver resection during the same period including six left lateral sectionectomies and 11 left hemihepatectomies. The groups were similar with regard to age, gender, tumor type, and tumor size. There were no significant differences in perioperative outcome such as operative time, intraoperative blood loss, postoperative liver function tests, complication rate, and hospital stay between robotic liver resection and laparoscopic liver resection. However, the medical cost was higher in the robotic group.ConclusionsRobotic liver resection is a safe and feasible option for liver resection in experienced hands. The authors suggest that since the robotic surgical system provides sophisticated advantages, the retrenchment of medical cost for the robotic system in addition to refining its liver transection tool may substantially increase its application in clinical practice in the near future.

Implication of lymph node metastasis detected on 18F-FDG PET/CT for surgical planning in patients with peripheral intrahepatic cholangiocarcinoma.

Objectives Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy after hepatocellular carcinoma. ICC can be divided into 2 types according to their location: peripheral and hilar types. Intense 18F-FDG uptake on PET was reported in peripheral ICC. However, the usefulness of PET/CT in detecting tumors and predicting prognosis in peripheral ICC has not been fully evaluated. In this study, we evaluated the clinical role of 18F-FDG PET/CT to predict the recurrence after the curative resection in patients with surgically indicated peripheral ICC. Methods Eighteen patients with ICC underwent preoperative CT and 18F-FDG PET/CT scans. SUVmax of tumor, tumor to normal liver SUV ratio (TNR), lymph node status evaluated by 18F-FDG PET/CT, tumor and lymph node size measured by CT, vascular invasion confirmed by pathology, and satellite nodules found on CT were compared between 1-year recurrence group and recurrence-free group by chi-square test. Results Of total 23 measurable lymph nodes, 4 nodes were positive and other 19 nodes were negative or equivocal on CT. Among those 23 nodes, 9 nodes were positive and other 14 nodes were negative on 18F-FDG PET/CT. The sensitivity and specificity of CT were 20.0% and 86.4%, and those of 18F-FDG PET/CT were 80.0% and 92.3%. In the comparison between 1-year recurrent and nonrecurrent groups, lymph node metastasis detected on 18F-FDG PET/CT had statistically positive correlation with the 1-year recurrence after surgical resection (P = 0.02). Other factors showed no statistically significant difference between the groups. Conclusion We found that lymph node metastasis detected on 18F-FDG PET/CT correlated positively with 1-year recurrence after surgical resection in patients with peripheral ICC.

Liver abscess developed after cadaveric liver transplantation due to ligation of an accessory right hepatic artery of the donor graft

It is important that extrahepatic arteries are identified precisely at the time of graft procurement. We present a case where the accessory right hepatic artery of the liver was ligated leading to postoperative liver abscess formation in the liver graft. A forty-seven-year-old female patient diagnosed with liver cirrhosis underwent orthotopic cadaveric liver transplantation due to altered mentality. The donor graft showed a variant of the hepatic artery anatomy where an accessory right hepatic artery arose from the superior mesenteric artery. This artery was accidentally transected during procurement. Since the back bleeding test using perfusion fluid was good, the artery was ligated. Postoperative abdominal computed tomography scan revealed a 6 cm low attenuating lesion in the liver. The patient underwent conservative treatment. We believe that even small accessory arteries (1 to 2 mm) should be reconstructed whenever possible to avoid postoperative complications such as liver abscess.

Use of right lobe graft with type IV portal vein accompanied by type IV biliary tree in living donor liver transplantation: Report of a case

Anatomic variations of the portal vein (PV) and bile duct (BD) are more common on the right lobe as compared with left lobe grafts in living donor liver transplantation (LDLT). We recently experienced a case of LDLT for hepatocellular carcinoma combined with liver cirrhosis secondary to hepatitis B virus and hepatitis C virus infection. The only available donor had right lobe graft with type IV PV associated with type IV BD. The patient underwent relaparotomy for PV stenting due to PV stenosis. Percutaneous transhepatic biliary drainage was done for a stricture at the site of biliary reconstruction. Thereafter, the patient was discharged in good health. Our experience suggests that, the use of right lobe graft with type IV PV accompanied by type IV BD should be the last choice for LDLT, because of its technical difficulty and risks of associated complications.

Metastatic hepatocellular carcinoma to the parotid gland: Case report and review of the literature

INTRODUCTION Hepatocellular carcinoma, the most frequent primary hepatic tumor, metastasizes in more than 50% of cases. However, parotid gland metastatic HCCs are very uncommon. We report a patient in whom the finding of a left parotid mass revealed metastatic HCC. PRESENTATION OF CASE A thirty-six-year-old male presented with a round palpable left neck mass that persisted for 3 months. He had received right hemihepatectomy for hepatocellular carcinoma (HCC). Preoperative evaluation revealed a benign tumor of the parotid gland. We performed superficial parotidectomy. Metastatic hepatocellular carcinoma of the parotid gland was diagnosed. DISCUSSION Although HCC metastases to the oral cavity have been reported, to date, only 4 cases HCC metastasis to the parotid gland have been reported. Although clinicians and cytopathologists alike both agree that salivary gland fine needle aspiration biopies (FNABs) are highly useful and safe diagnostic alternatives to biopsies and resections, we believe that in specific clinical situations, awareness of potential diagnostic pitfalls in salivary gland FNAB is a necessary part of the microscopic interpretations of these lesions. CONCLUSION Although rare, since HCC can metastasize to the parotid gland, high suspicion should be maintained in a patient presenting with a parotid mass with a history of HCC. In addition, since potential diagnostic pitfalls in salivary gland fine-needle aspiration (FNA) biopsies exist, incisional or excisional biopsy may be necessary for definite diagnosis of metastatic HCC to the parotid gland.

Biliary phytobezoar resulting in intestinal obstruction.

Phytobezoar is the most common type of bezoar. It is composed of indigestible vegetable matter and is usually found in the stomach. Biliary phytobezoar is extremely rare and difficult to diagnose preoperatively. The pathogenesis is not clear, and there have been only a few reports of biliary bezoars associated with sphincteric impairment at the ampulla of Vater. Here, we present a report of biliary bezoar that resulted in jejunal obstruction. We were unable to identify the bezoar in the extrahepatic bile duct until it obstructed the small bowel lumen. To our knowledge, this is the first report of small bowel obstruction resulting from migration of a biliary bezoar.

Extracorporeal Hepatic Venous Bypass During En Bloc Resection of Right Trisection, Caudate Lobe, and Inferior Vena Cava: A Novel Technique to Avoid Hypothermic Perfusion

Complete resection can provide the best chance for longterm survival in primary and secondary liver tumors. With the advances in surgical techniques, perioperative management, and frequent use of effective neoadjuvant chemotherapy, there is a higher rate of liver tumors being resected than ever before. However, depending on the size, extent of the tumor, or its location close to critical structures, some liver tumors cannot be resected using a conventional approach. In selected cases for these types of situations, the techniques of total vascular exclusion with hypothermic perfusion such as in situ, ex situ, and ante situm liver resection can be used and offer new chances for R0 resection in otherwise unresectable cases. Hypothermic perfusion with organ preservation solution under total vascular exclusion is the essential part of these procedures, so that the liver can tolerate ischemia for an extended period of time. However, prolonged cold ischemia can act as another source of ischemia-reperfusion injury to the future liver remnant with marginal volume in most cases, which can potentially be critical to patient recovery. In addition, the portal vein has to be divided or cannulated for infusion of preservation solution in all techniques, and the hepatic artery and bile duct have to be divided in ex situ liver resection, which increases the risk of potential complications. We report here, for the first time, a novel technique of extracorporeal hepatic venous bypass to avoid hypothermic liver perfusion during complex hepatectomy.

Risk factors for cancer recurrence or death within 6 months after liver resection in patients with colorectal cancer liver metastasis

Purpose The aim of this study was to find risk factors for early recurrence (ER) and early death (ED) after liver resection for colorectal cancer liver metastasis (CRCLM). Methods Between May 1990 and December 2011, 279 patients underwent liver resection for CRCLM at Korea University Medical Center. They were assigned to group ER (recurrence within 6 months after liver resection) or group NER (non-ER; no recurrence within 6 months after liver resection) and group ED (death within 6 months after liver resection) or group NED (alive > 6 months after liver resection). Results The ER group included 30 patients (10.8%) and the NER group included 247 patients (89.2%). The ED group included 18 patients (6.6%) and the NED group included 253 patients (93.4%). Prognostic factors for ER in a univariate analysis were poorly differentiated colorectal cancer (CRC), synchronous metastasis, ≥5 cm of liver mass, ≥50 ng/mL preoperative carcinoembryonic antigen level, positive liver resection margin, and surgery alone without perioperative chemotherapy. Prognostic factors for ED in a univariate analysis were poorly differentiated CRC, positive liver resection margin, and surgery alone without perioperative chemotherapy. Multivariate analysis showed that poorly differentiated CRC, ≥5-cm metastatic tumor size, positive liver resection margin, and surgery alone without perioperative chemotherapy were independent risk factors related to ER. For ED, poorly differentiated CRC, positive liver resection margin, and surgery alone without perioperative chemotherapy were risk factors in multivariate analysis. Conclusion Complete liver resection with clear resection margin and perioperative chemotherapy should be carefully considered when patients have the following preoperative risk factors: metastatic tumor size ≥ 5 cm and poorly differentiated CRC.

Usefulness of radioembolization in identifying patients with favorable tumor biology before living donor liver transplantation.

inherent to any observational cohort study, including a small sample size representing HL practice at a single center, potentiating the risk of a type 2 error. In this study, the heart was the primary organ for allocation in all HL recipients, which may not be representative of the national HL experience (8). The effects of bypassing candidates on the wait list are most likely pertinent at the first few match run positions, which we believe justifies our inclusion of only the first five candidates. Confirmation of the findings from this study awaits analysis of national data. In summary, this analysis suggests that liver candidates bypassed by HL dual transplants do not incur a survival disadvantage. Our intention is to highlight the previously unstudied consequences of dual organ transplantation and spur further inquiries into the indications and allocation practices for dual organ transplantation. Guidelines for dual-organ transplantation will ultimately need to be established which provide equipoise to single as well as dual organ candidates.

Can propranolol be a viable option for the treatment of small-for-size syndrome?

TO THE EDITORS: Small-for-size (SFS) syndrome is characterized by the appearance of cholestasis, prolonged coagulopathy, and intractable ascites at the end of the first week after transplantation. Factors such as excessive portal inflow, graft congestion, a small functional liver mass, and inadequate intragraft responses have been considered as causes of SFS syndrome after living donor liver transplantation (LDLT). There have been a number of studies on surgical maneuvers for preventing SFS syndrome, but there have been very few clinical reports about pharmacological treatments. We present our experience with using propranolol (PP) to treat SFS syndrome that persisted after splenic artery embolization (SPE) in an LDLT patient. A 37-year-old Asian female with hepatitis B– related end-stage liver disease underwent LDLT with a left lobe from her 51-year-old brother-inlaw. The Model for End-Stage Liver Disease score was 19, and the Child-Turcotte-Pugh score was 12. The actual graft weight was 466 g, and the graftto-recipient weight ratio was 0.81. Thrombectomy was performed before the graft anastomosis because of severe and extensive portal vein thrombosis. Because the intraoperative portogram revealed sluggish flow of the portal vein, a portal vein stent was inserted. The left renal vein was ligated to negate the effects of the splenorenal shunt, and so was the large collateralized inferior mesenteric vein to improve the portal flow. The measured portal pressure was 16 mm Hg after stent insertion and the ligation of collaterals, and this suggested that the possibility of developing SFS syndrome was low. As a result, the splenic artery was not ligated. Postoperatively, the total bilirubin level started to increase on postoperative day (POD) 3 and reached 18.59 mg/dL on POD 7. Also, the amount of drainage increased to more than 2 L/day. After ruling out other potential causes of hyperbilirubinemia, we suspected SFS syndrome and decided to perform SPE. During the procedure, we also measured the hepatic vein wedge pressure, which decreased from 33 to 25 mm Hg after embolization. However, the total bilirubin level continued to rise to 25.29 mg/dL, and the prothrombin time was still 35% to 40% of the normal value. We decided to administer PP orally while we monitored the blood pressure and the heart rate. The dosage was titrated to reduce the resting heart rate by 25%. Although initially the total bilirubin level continued to increase, it peaked at 28.54 mg/dL on POD 11 and then began to decrease (Fig. 1). After 4 days of medication with PP, the hepatic vein wedge pressure decreased from 25 to 14 mm Hg. The patient was discharged home with excellent health 5 weeks after the operation. Although SFS syndrome is a multifactorial process, it is generally accepted that portal hyperperfusion injury is the overriding factor. However, because adequate portal flow is vital for graft function, the critical issue is the maintenance of portal perfusion within a reasonable range. Some authors have used the portal pressure after arterial reperfusion as a guide, whereas Troisi et al. used portal flow measurements. Yagi et al. measured both the pressure and the flow and ligated spontaneous collaterals to keep the portal flow higher than 800 mL/minute, but they prioritized keeping the portal pressure below 20 mm Hg as part of their intraoperative decision making. Because the measured portal pressure for our patient after portal vein stent insertion and collateral ligation was 16 mm Hg, the possibility of developing SFS syndrome was considered low. Although various surgical methods of portal flow modulation for preventing SFS syndrome have been described, pharmacological options have not been well investigated. Medications such as PP, somatostatin, and terlipressin can decrease the portal flow and pressure reliably and reproducibly in patients with cirrhosis, but they have not been used widely in the setting of SFS syndrome. One could argue that the condition of the patient did not improve solely with the use of PP because of the early administration of PP after SPE and the continuing rise of the