Risk Prediction Model Based on Magnetic Resonance Elastography-Assessed Liver Stiffness for Predicting Posthepatectomy Liver Failure in Patients with Hepatocellular Carcinoma

Background/Aims@#Posthepatectomy liver failure (PHLF) is a major complication that increases mortality in patients with hepatocellular carcinoma after surgical resection. The aim of this retrospective study was to evaluate the utility of magnetic resonance elastography-assessed liver stiffness (MRE-LS) for the prediction of PHLF and to develop an MRE-LS-based risk prediction model. @*Methods@#A total of 160 hepatocellular carcinoma patients who underwent surgical resection with available preoperative MRE-LS data were enrolled. Clinical and laboratory parameters were collected from medical records. Logistic regression analyses were conducted to identify the risk factors for PHLF and develop a risk prediction model. @*Results@#PHLF was present in 24 patients (15%). In the multivariate logistic analysis, high MRE-LS (kPa; odds ratio [OR] 1.49, 95% confidence interval [CI] 1.12 to 1.98, p=0.006), low serum albumin (≤3.8 g/dL; OR 15.89, 95% CI 2.41 to 104.82, p=0.004), major hepatic resection (OR 4.16, 95% CI 1.40 to 12.38, p=0.014), higher albumin-bilirubin score (>–0.55; OR 3.72, 95% CI 1.15 to 12.04, p=0.028), and higher serum α-fetoprotein (>100 ng/mL; OR 3.53, 95% CI 1.20 to 10.40, p=0.022) were identified as independent risk factors for PHLF. A risk prediction model for PHLF was established using the multivariate logistic regression equation. The area under the receiver operating characteristic curve (AUC) of the risk prediction model was 0.877 for predicting PHLF and 0.923 for predicting grade B and C PHLF. In leave-one-out cross-validation, the risk model showed good performance, with AUCs of 0.807 for all-grade PHLF and 0. 871 for grade B and C PHLF. @*Conclusions@#Our novel MRE-LS-based risk model had excellent performance in predicting PHLF, especially grade B and C PHLF.

Outcomes after liver transplantation in Korea: Incidence and risk factors from Korean transplantation registry

Background/Aims@#To analyze the incidence and risk factors of outcomes after liver transplantation (LT) in the Korean population. @*Methods@#This study analyzed data from the liver cohort of Korean Organ Transplantation Registry (KOTRY) who had LT between May 2014 and December 2017. Study measures included the incidence of post-LT outcomes in recipients of living donor LT (LDLT) and deceased donor LT (DDLT). Cox multivariate proportional hazards model was used to determine the potential risk factors predicting the outcomes. @*Results@#A total of 2,563 adult recipients with LT (LDLT, n=1,956; DDLT, n=607) were included, with mean±standard deviation age of 53.9±8.9 years, and 72.2% were male. The post-LT outcomes observed in each LDLT and DDLT recipients were death (4.0% and 14.7%), graft loss (5.0% and 16.1%), rejection (7.0% and 12.0%), renal failure (2.7% and 13.8%), new onset of diabetes (12.5% and 15.4%), and hepatocellular carcinoma (HCC) recurrence (both 6.7%). In both LDLT and DDLT recipients, the most common post-LT complications were renal dysfunction (33.6% and 51.4%), infection (26.7% and 48.4%), and surgical complication (22.5% and 23.9%). Incidence of these outcomes were generally higher among recipients of DDLT than LDLT. Multivariate analysis indicated recipient age and DDLT as significant risk factors associated with death and graft loss. DDLT and ABO incompatible transplant were prognostic factors for rejection, and HCC beyond Milan criteria at pre-transplant was a strong predictor of HCC recurrence. @*Conclusions@#This study is a good indicator of the post-LT prognosis in the Korean population and suggests a significant burden of post-LT complications.

Outcomes after liver transplantation in Korea: Incidence and risk factors from Korean transplantation registry

Background/Aims@#To analyze the incidence and risk factors of outcomes after liver transplantation (LT) in the Korean population. @*Methods@#This study analyzed data from the liver cohort of Korean Organ Transplantation Registry (KOTRY) who had LT between May 2014 and December 2017. Study measures included the incidence of post-LT outcomes in recipients of living donor LT (LDLT) and deceased donor LT (DDLT). Cox multivariate proportional hazards model was used to determine the potential risk factors predicting the outcomes. @*Results@#A total of 2,563 adult recipients with LT (LDLT, n=1,956; DDLT, n=607) were included, with mean±standard deviation age of 53.9±8.9 years, and 72.2% were male. The post-LT outcomes observed in each LDLT and DDLT recipients were death (4.0% and 14.7%), graft loss (5.0% and 16.1%), rejection (7.0% and 12.0%), renal failure (2.7% and 13.8%), new onset of diabetes (12.5% and 15.4%), and hepatocellular carcinoma (HCC) recurrence (both 6.7%). In both LDLT and DDLT recipients, the most common post-LT complications were renal dysfunction (33.6% and 51.4%), infection (26.7% and 48.4%), and surgical complication (22.5% and 23.9%). Incidence of these outcomes were generally higher among recipients of DDLT than LDLT. Multivariate analysis indicated recipient age and DDLT as significant risk factors associated with death and graft loss. DDLT and ABO incompatible transplant were prognostic factors for rejection, and HCC beyond Milan criteria at pre-transplant was a strong predictor of HCC recurrence. @*Conclusions@#This study is a good indicator of the post-LT prognosis in the Korean population and suggests a significant burden of post-LT complications.

Hepatitis B Prophylaxis after Liver Transplantation in Korea: Analysis of the KOTRY Database

BACKGROUND@#Prophylaxis for hepatitis B virus (HBV) recurrence is essential after liver transplantation (LT) in HBV-associated recipients. We conducted real-world analysis of HBV prophylaxis after LT in the Korean population.@*METHODS@#Korean Organ Transplantation Registry (KOTRY) database and additionally collected data (n = 326) were analyzed with special reference to types of HBV prophylaxis.@*RESULTS@#The study cohort comprised 267 cases of living-donor LT and 59 cases of deceased-donor LT. Hepatocellular carcinoma (HCC) was diagnosed in 232 (71.2%) of these subjects. Antiviral agents were used in 255 patients (78.2%) prior to LT. HBV DNA was undetectable in 69 cases (21.2%) and detectable over wide concentrations in the other 257 patients (78.8%) prior to LT. Polymerase chain reaction analysis of the store blood samples detected HBV DNA in all patients, with 159 patients (48.9%) showing concentrations > 100 IU/mL. Post-transplant HBV regimens during the first year included combination therapy in 196 (60.1%), hepatitis B immunoglobulin (HBIG) monotherapy in 121 (37.1%), and antiviral monotherapy in 9 (2.8%). In the second post-transplant year, these regimens had changed to combination therapy in 187 (57.4%), HBIG monotherapy in 112 (34.4%), and antiviral monotherapy in 27 (8.3%). Trough antibody to hepatitis B surface antigen titers > 500 IU/mL and >1,000 IU/mL were observed in 61.7% and 25.2%, respectively. The mean simulative half-life of HBIG was 21.6 ± 4.3 days with a median 17.7 days. Up to 2-year follow-up period, HCC recurrence and HBV recurrence developed in 18 (5.5%) and 6 (1.8%), respectively. HCC recurrence developed in 3 of 6 patients with HBV recurrence.@*CONCLUSION@#Combination therapy is the mainstay of HBV prophylaxis protocols in a majority of Korean LT centers, but HBIG was often administered excessively. Individualized optimization of HBIG treatments using SHL is necessary to adjust the HBIG infusion interval.

18F-fluorodeoxyglucose PET/CT as an independent predictor for patients with hepatocellular carcinoma combined with major portal vein tumor thrombus

Purpose@#Hepatocellular carcinoma (HCC) patients with major portal vein tumor thrombosis (mPVTT) complications were generally characterized by extremely poor prognoses. The aim of this study was to explore the role of 18F-fluorodeoxyglucose (18F-FDG) PET/CT imaging in predicting HCC complicated by mPVTT. @*Methods@#Five hundred one HCC patients received surgery in our hospital during November 2008 to December 2014, among which 32 patients (6.4%) were diagnosed as HCC complicated by mPVTT. Six cases were excluded for reasons of complex medical conditions, including 2 cases of salvage liver transplantation, 2 cases of re-resection, 1 case of mPVTT combined with inferior vina cava tumor thrombosis, and 1 case of residual portal vein tumor thrombosis. Ultimately, 26 cases were enrolled in this study. The maximal tumor standardized uptake value (SUVmax) was identified as a predictive factor and detected. The univariate and multivariate regression analyses were performed to identify the prognostic factors for recurrence-free survival (RFS) and overall survival (OS) of HCC patients complicated by mPVTT. @*Results@#Our results showed that the median OS was 16 months. The 1-, 3-, and 5-year cumulative OS was 55.6%, 31.7%, and 31.7%, respectively. The multivariate regression analysis revealed that SUVmax ≥ 4.65 was the only independent risk factor for RFS and OS. @*Conclusion@#SUVmax was an independent predictor for RFS and OS of patients suffering from both HCC and mPVTT. L ow SUVmax could serve as an effective factor for selecting candidates with low recurrence risks and for helping with improving patient survival after surgical resection.

Hepatitis B Prophylaxis after Liver Transplantation in Korea: Analysis of the KOTRY Database

BACKGROUND: Prophylaxis for hepatitis B virus (HBV) recurrence is essential after liver transplantation (LT) in HBV-associated recipients. We conducted real-world analysis of HBV prophylaxis after LT in the Korean population.METHODS: Korean Organ Transplantation Registry (KOTRY) database and additionally collected data (n = 326) were analyzed with special reference to types of HBV prophylaxis.RESULTS: The study cohort comprised 267 cases of living-donor LT and 59 cases of deceased-donor LT. Hepatocellular carcinoma (HCC) was diagnosed in 232 (71.2%) of these subjects. Antiviral agents were used in 255 patients (78.2%) prior to LT. HBV DNA was undetectable in 69 cases (21.2%) and detectable over wide concentrations in the other 257 patients (78.8%) prior to LT. Polymerase chain reaction analysis of the store blood samples detected HBV DNA in all patients, with 159 patients (48.9%) showing concentrations > 100 IU/mL. Post-transplant HBV regimens during the first year included combination therapy in 196 (60.1%), hepatitis B immunoglobulin (HBIG) monotherapy in 121 (37.1%), and antiviral monotherapy in 9 (2.8%). In the second post-transplant year, these regimens had changed to combination therapy in 187 (57.4%), HBIG monotherapy in 112 (34.4%), and antiviral monotherapy in 27 (8.3%). Trough antibody to hepatitis B surface antigen titers > 500 IU/mL and >1,000 IU/mL were observed in 61.7% and 25.2%, respectively. The mean simulative half-life of HBIG was 21.6 ± 4.3 days with a median 17.7 days. Up to 2-year follow-up period, HCC recurrence and HBV recurrence developed in 18 (5.5%) and 6 (1.8%), respectively. HCC recurrence developed in 3 of 6 patients with HBV recurrence.CONCLUSION: Combination therapy is the mainstay of HBV prophylaxis protocols in a majority of Korean LT centers, but HBIG was often administered excessively. Individualized optimization of HBIG treatments using SHL is necessary to adjust the HBIG infusion interval.

Hepatitis B Prophylaxis after Liver Transplantation in Korea: Analysis of the KOTRY Database

BACKGROUND@#Prophylaxis for hepatitis B virus (HBV) recurrence is essential after liver transplantation (LT) in HBV-associated recipients. We conducted real-world analysis of HBV prophylaxis after LT in the Korean population.@*METHODS@#Korean Organ Transplantation Registry (KOTRY) database and additionally collected data (n = 326) were analyzed with special reference to types of HBV prophylaxis.@*RESULTS@#The study cohort comprised 267 cases of living-donor LT and 59 cases of deceased-donor LT. Hepatocellular carcinoma (HCC) was diagnosed in 232 (71.2%) of these subjects. Antiviral agents were used in 255 patients (78.2%) prior to LT. HBV DNA was undetectable in 69 cases (21.2%) and detectable over wide concentrations in the other 257 patients (78.8%) prior to LT. Polymerase chain reaction analysis of the store blood samples detected HBV DNA in all patients, with 159 patients (48.9%) showing concentrations > 100 IU/mL. Post-transplant HBV regimens during the first year included combination therapy in 196 (60.1%), hepatitis B immunoglobulin (HBIG) monotherapy in 121 (37.1%), and antiviral monotherapy in 9 (2.8%). In the second post-transplant year, these regimens had changed to combination therapy in 187 (57.4%), HBIG monotherapy in 112 (34.4%), and antiviral monotherapy in 27 (8.3%). Trough antibody to hepatitis B surface antigen titers > 500 IU/mL and >1,000 IU/mL were observed in 61.7% and 25.2%, respectively. The mean simulative half-life of HBIG was 21.6 ± 4.3 days with a median 17.7 days. Up to 2-year follow-up period, HCC recurrence and HBV recurrence developed in 18 (5.5%) and 6 (1.8%), respectively. HCC recurrence developed in 3 of 6 patients with HBV recurrence.@*CONCLUSION@#Combination therapy is the mainstay of HBV prophylaxis protocols in a majority of Korean LT centers, but HBIG was often administered excessively. Individualized optimization of HBIG treatments using SHL is necessary to adjust the HBIG infusion interval.

18F-fluorodeoxyglucose PET/CT as an independent predictor for patients with hepatocellular carcinoma combined with major portal vein tumor thrombus

Purpose@#Hepatocellular carcinoma (HCC) patients with major portal vein tumor thrombosis (mPVTT) complications were generally characterized by extremely poor prognoses. The aim of this study was to explore the role of 18F-fluorodeoxyglucose (18F-FDG) PET/CT imaging in predicting HCC complicated by mPVTT. @*Methods@#Five hundred one HCC patients received surgery in our hospital during November 2008 to December 2014, among which 32 patients (6.4%) were diagnosed as HCC complicated by mPVTT. Six cases were excluded for reasons of complex medical conditions, including 2 cases of salvage liver transplantation, 2 cases of re-resection, 1 case of mPVTT combined with inferior vina cava tumor thrombosis, and 1 case of residual portal vein tumor thrombosis. Ultimately, 26 cases were enrolled in this study. The maximal tumor standardized uptake value (SUVmax) was identified as a predictive factor and detected. The univariate and multivariate regression analyses were performed to identify the prognostic factors for recurrence-free survival (RFS) and overall survival (OS) of HCC patients complicated by mPVTT. @*Results@#Our results showed that the median OS was 16 months. The 1-, 3-, and 5-year cumulative OS was 55.6%, 31.7%, and 31.7%, respectively. The multivariate regression analysis revealed that SUVmax ≥ 4.65 was the only independent risk factor for RFS and OS. @*Conclusion@#SUVmax was an independent predictor for RFS and OS of patients suffering from both HCC and mPVTT. L ow SUVmax could serve as an effective factor for selecting candidates with low recurrence risks and for helping with improving patient survival after surgical resection.

Can we delineate preoperatively the right and ventral margins of caudate lobe of the liver?

PURPOSE: Complete removal of the caudate lobe, which is sometimes necessary, is accomplished via isolated caudate lobectomy or hepatectomy that includes the caudate lobe. It is impossible, however, to confirm the right and ventral margins of the caudate lobe by preoperative imaging. This study was undertaken to determine whether we could identify the right and ventral margins of the caudate lobe preoperatively using Synapse 3D visualization software. METHODS: Ninety-four preoperative 3-dimensional (3D) computed tomographic images (1-mm slices) of the liver from candidate donors were examined. The images of the caudate lobe were subjected to a counter-staining method according to Synapse 3D to delineate their dimensions. We first examined whether the right margin of the caudate lobe exceeded the plane formed by the root of the right hepatic vein (RHV) and the right side of the inferior vena cava (IVC). Second, we determined whether the ventral margin of the caudate lobe exceeded the plane formed by the root of the middle hepatic vein (MHV) and the root of the RHV. RESULTS: For the right margin, 17 cases (18%) exceeded the RHV-IVC plane by a mean of 10.2 mm (range, 2.4–27.2 mm). For the ventral margin, 28 cases (30%) exceeded the MHV-RHV plane by a mean of 17.4 mm (range, 1.2–49.1 mm). CONCLUSION: Evaluating the anatomy of caudate lobe using Synapse 3D preoperatively could be helpful for more precise anatomical resection of the caudate lobe.

The 7th/8th American Joint Committee on Cancer and the Modified Union for International Cancer Control Staging System for Hepatocellular Carcinoma

PURPOSE: Although many staging systems have been proposed for hepatocellular carcinoma (HCC), there is no globally accepted system due to the extreme heterogeneity of the disease. We aimed to compare the results of the 7th/8th American Joint Committee on Cancer (AJCC) and the modified Union for International Cancer Control (mUICC) staging systems in patients with HCC. MATERIALS AND METHODS: We collected data from 792 patients who underwent hepatic resection at our center. The Kaplan-Meier method was used to determine disease-free survival and overall survival. To evaluate homogeneity, ‘-2 log likelihood’ was calculated using Cox proportional hazards regression. To measure discriminatory ability, the linear trend chi method and the Cochran-Armitage test for trend were used. The ability to accurately predict survival was verified by cross-validation analysis. RESULTS: Kaplan-Meier curves for disease-free survival and overall survival showed mUICC to be superior to the 7th/8th AJCC. The homogeneity test indicated that mUICC was the best for both disease-free survival and overall survival. In the discriminatory ability test, the chi-square value of mUICC was the best for disease-free survival, while the 7th AJCC had the best value for overall survival. In the cross-validation analysis, all three staging systems had significant predictive power. CONCLUSION: mUICC seemed to be superior to the 7th/8th AJCC after analyzing the data of our surgical patients, although the geographic heterogeneity of HCC might result in differences between the staging systems. We believe that, while the three staging systems allow for the clear stratification of patients into prognostic groups, mUICC may be more appropriate in HCC.

Surgical treatment for hepatocellular carcinoma with bile duct invasion

PURPOSE: There is still some debate on surgical procedures for hepatocellular carcinoma (HCC) patients with bile duct tumor thrombi (BDTT, Ueda type 3 or 4). What is adequate extent of liver resection for curative treatment? Is extrahepatic bile duct resection mandatory for cure? The aim of this study is to answer these questions. METHODS: Between February 1994 and December 2012, 877 consecutive HCC patients underwent hepatic resection at Ajou University Hospital. Thirty HCC patients (3.4%) with BDTT (Ueda type 3 or 4) were retrospective reviewed in this study. RESULTS: In total, 20 patients enrolled in this study were divided into 2 groups: patients who underwent hemihepatectomy with extrahepatic bile duct resection (group 1, n = 10) and with only removal of BDTT (group 2, n = 10). The 1-, 3- and 5-year overall survival rates were 75.0%, 50.0%, and 27.8%, respectively. The 1-, 3-, and 5-year survival rates of group 1 were 100.0%, 80.0%, and 45.7%, and those of group 2 were 50.0%, 20.0%, and 10.0%, respectively (P = 0.014). The 1-, 3-, and 5-year recurrences free survival rates of group 1 were 90.0%, 70.0%, and 42.0%, and those of group 2 were 36.0%, 36.0%, and 0%, respectively (P = 0.014). Thrombectomy and infiltrative growth type (Ig) were found as independent prognostic factors for recurrence free survival by multivariate analysis. Thrombectomy, Ig, and high indocyanine green retention rate at 15 minutes were found as independent prognostic factors for overall survival by multivariate analysis. CONCLUSION: We suggest that the appropriate surgical procedure for icteric HCC patients should be comprised of ipsilateral hemihepatectomy with caudate lobectomy and extrahepatic bile duct resection.

Blood Neutrophil-to-Lymphocyte Ratio Predicts Tumor Recurrence in Patients with Hepatocellular Carcinoma within Milan Criteria after Hepatectomy

PURPOSE: The systemic inflammation biomarker, Neutrophil-to-Lymphocyte Ratio (NLR), has been reported as one of the adverse prognostic factors for hepatocellular carcinoma (HCC) patient. The purpose of this study was to evaluate whether NLR could predict the risk of recurrence and death for the HCC patient, according to Milan criteria after hepatectomy. MATERIALS AND METHODS: Retrospective analysis was performed on a database of HCC patients who underwent hepatectomy between March 2001 and December 2011. The cutoff value of NLR was decided by receiver operating characteristic (ROC) curve analysis. Univariate and multivariate regression analyses were performed to identify predictive factors of recurrence and death. RESULTS: A total of 213 patients were included in the present study. The median follow-up period was 48 months. One hundred and seven patients were experienced tumor recurrence; forty of them recurred within 12 months (early recurrence). NLR ≥1.505, albumin ≤3.75 g/dL, microvascular invasion and high grade of cirrhosis were found to be independent factors for adverse recurrence-free survival in multivariate regression analysis. And NLR ≥1.945 was also found as a prognosis factor for early recurrence by univariate regression analysis. CONCLUSION: Elevated preoperative NLR can be easily obtained and reliable biomarker for assessing the tumor recurrence and early recurrence of Milan criteria HCC after the initial hepatectomy.

The Feasibility of Right Posterior Sector Graft in the Adult Living Donor Liver Transplantation / 대한이식학회지

BACKGROUND: The aim of this study is to evaluate the feasibility of living donor liver transplantation (LDLT) using an right posterior sector (RPS) graft selected by liver volumetry of living donors. METHODS: From April 2008 to August 2014, 132 LDLTs were performed in our hospital. Of these, 20 recipients (15.1%) received an RPS graft. Perioperative data of LDLTs using an RPS graft were analyzed retrospectively. RESULTS: Mean of the Model for End-stage Liver Disease score of the 20 recipients was 12.1+/-6.2. The mean right liver volume was 72.4%+/-3.1% of total liver volume (TLV) and the mean volume of RPS was 38.2%+/-5.3% of TLV. Anatomical anomalies were found in the portal vein (PV) of 14 donors (70%), in the hepatic artery of one donor (5%), and bile duct of seven donors (35%). All donors were discharged with normal liver function. Two donors (10%) developed bile leakage after RPS donation. None of the recipients experienced complication associated with hepatic artery and PV anastomosis. One recipient had in-hospital mortality due to pneumonia. The remaining 19 recipients were discharged with good graft function. Four recipients (20%) developed biliary stricture and one (5%) had a liver abscess during follow-up. CONCLUSIONS: The RPS donor had a high incidence of abnormal anatomy of PV. LDLT using an RPS graft might have high incidence of biliary complications. We think that selection of an RPS graft from a donor with an inappropriately large right lobe volume could expand the donor pool and be a feasible option in LDLT.

Epidemiology and Clinical Features of Post-Transplant Bloodstream Infection: An Analysis of 222 Consecutive Liver Transplant Recipients

BACKGROUND: Bloodstream infection (BSI) is a significant cause of morbidity and mortality in liver transplant (LT) recipients. This study aimed to investigate the epidemiology and clinical features of post-transplant BSI in LT recipients. MATERIALS AND METHODS: The microbiology, frequency, and outcome of post-transplant BSI in the first year after LT were retrospectively analyzed in 222 consecutive patients who had received liver transplants at a single center between 2005 and 2011. The risk factors for post-transplant BSI and death were evaluated. RESULTS: During a 1-year period after LT, 112 episodes of BSI occurred in 64 of the 222 patients (28.8%). A total of 135 microorganisms were isolated from 112 BSI episodes including 18 polymicrobial episodes. The median time to BSI onset ranged from 8 days for Klebsiella pneumoniae to 101 days for enterococci, and the overall median for all microorganisms was 28 days. The most frequent pathogens were Enterobacteriaceae members (32.5%), enterococci (17.8%), yeasts (14.0%), Staphylococcus aureus (10.3%), and Acinetobacter baumannii (10.3%); most of them showed resistance to major antibiotics. The major sources of BSI were biliary tract (36.2%), abdominal and/or wound (28.1%), and intravascular catheter (18.5%) infections. The independent risk factors for post-transplant BSI were biliary complications (odds ratio [OR]: 2.91, 95% confidence interval [CI]: 1.29 to 6.59, P = 0.010) and longer hospitalization in the intensive care unit (OR: 1.04, 95% CI: 1.00 to 1.08, P < 0.001) after LT. BSI was an independent risk factor for death (hazard ratio [HR]: 3.92, 95% CI: 2.22 to 6.91, P < 0.001), with a poorer survival rate observed in patients with BSI than in those without BSI (1-year survival rate: 60.0% versus 89.5%, respectively, P < 0.001) after LT. The strongest predictors for death in patients with BSI were hepatocellular carcinoma (HR: 3.82, 95% CI: 1.57 to 9.32, P = 0.003), candidemia (HR: 3.71, 95% CI: 1.58 to 8.71, P = 0.003), polymicrobial bacteremia (HR: 3.18, 95% CI: 1.39 to 7.28, P = 0.006), and post-transplant hemodialysis (HR: 2.44, 95% CI: 1.02 to 5.84, P = 0.044). CONCLUSIONS: BSI was a frequent post-transplant complication, and most of the causative pathogens were multi-drug resistant. Biliary complications and BSIs resulting from biliary infection are major problems for LT recipients. The prevention of BSI and biliary complications is critical in improving prognosis in liver transplant recipients.

Variation or newly identified glissonian pedicles between the lateral and medial sections of the liver, using cadaver dissection / 대한외과학회지

PURPOSE: Studies of liver anatomy have developed alongside clinical achievements, as these types of research complement each other. The aim of this study is to determine whether or not the portal vein branches (P4d) in 'Nagino's trisectionectomy' exist, and to examine their characteristics using cadaver dissection. METHODS: From April 2012 to July 2012, 31 adult cadavers were delicately dissected. We defined a 'NewGP' as an extra glissonian pedicle (GP) other than the traditional GPs that supply segments II, III, IVa, and IVb in the ordinary direction, and anatomically located superior to the umbilical fissure (UF). RESULTS: We identified 'NewGPs' based on the UF and UF vein. The incidence of 'NewGPs' was 30/31 (96.8%). The diameter of the 'NewGPs' ranged from 3.5 to 5.6 mm, which was not significantly different from that of traditional GPs (II-, III-, or IV-GP), which have diameters ranging from 3.7 to 9.7 mm. CONCLUSION: We think that the P4d in 'Nagino's trisectionectomy' correspond to the 'IVa NewGP' and the additional pedicle. We believe the clinical significance of the 'NewGP' is to complement the traditional II, III, IVa, and IVb pedicles in supplying the liver.

Relationship between Psychological Profile of Living Donor for Liver Transplantation and Post-Surgical Pain Score, Opioid Analgesics Amounts and Duration / 대한정신약물학회지

OBJECTIVE: Living donor liver transplantation is a surgical treatment which could impose a heavy burden on both the recipient and the potential donor. Preoperative psychological evaluation of the potential donor is essential in protecting one's psychosocial well-being, as well as one's autonomy. In this research, we examined the correlation between the preoperative psychological profile of the potential donor and one's postoperative pain and opioid analgesic usage. METHODS: Retrospective review of the medical records of all living donors who had completed preoperative psychological evaluation in our transplantation center from January, 2010 to December, 2011 was done. Preoperative psychological evaluation included Minnesota Multiphasic Personality Inventory-2 (MMPI-2), Sentence Complete Test and an interview with a psychiatrist. Mean postoperative pain within 7 days after the surgery was evaluated. Dosages of all opioid analgesics were converted to equivalent dosage of morphine. RESULTS: Depression T-score showed a significant correlation with the duration of opioid analgesics usage (R2=0.306, F=12.363). Also, F score and dosage of opioid analgesics (R2=0.360, F=15.766), as well as Psychasthenia T- score and postoperative mean pain score (R2=0.137, F=4.448) showed significant correlation. CONCLUSION: Depression T-score, F score and Psychastenia T-score from MMPI-2 are well known to reflect one's depression, discontent, psychological instability and chronic anxiety. Such personalized and specified psychiatric intervention could help the donor to cope with post-surgical pain better.

Usefulness of the Pinch-Burn-Cut (PBC) technique for recipient hepatectomy in liver transplantation

BACKGROUNDS/AIMS: Surgical bleeding during recipient hepatectomy is a major concern in liver transplantation (LT). Effective intraoperative control of bleeding is necessary. In the Pinch-Burn-Cut (PBC) technique, a small amount of tissue around the dissection plane is pinched with forceps, electocauterized and gently cut. The present study sought to estimate the usefulness of the PBC technique in LT. METHODS: Between June 2007 and December 2010, 123 adult cases underwent LT in our center. Of these, 72 involved a recipient hepatectomy using the PBC technique (PBC group). and 51 involved the conventional technique (non-PBC group). Clinical parameters were compared between two groups. RESULTS: The amount of blood loss and related transfusions were significantly reduced, and the operating time was shorter in the PBC group than in the non-PBC group (p=0.006, p<0.05 and p=0.002, respectively). There was also shorter duration of mechanical ventilation after LT in the PBC group (p=0.017). The incidence of postoperative hemorrhage was lower in the PBC group than in the non-PBC group, but had no statistical significance between two group (19.6% vs. 8.3%, p=0.101). CONCLUSIONS: Our data suggest that the PBC technique is effective for bleeding control during recipient hepatectomy in LT.

Liver Transplantation for Hepatitis C Virus-Related Liver Disease in Korea / 대한이식학회지

BACKGROUND: A management protocol for hepatitis C virus (HCV) after liver transplantation (LT) has not been established in Korea. We therefore investigated HCV transplant protocols and post-transplant results from liver transplant centers in Korea. METHODS: The HCV protocol and medical data of individual cases from eight major liver transplant centers were compiled and analyzed. RESULTS: A post-transplant protocol biopsy was performed in only three centers. In these centers, HCV treatment was considered when pathological abnormalities were confirmed on the protocol biopsy (irrespective of liver function). In the other five centers, biopsies were performed when biochemical parameters were aggravated. Only two out of the eight centers performed preemptive or prophylactic therapy. A total of 5,663 adult LTs were performed between 2000 and 2010. HCV-related liver disease was responsible for 277 LTs (4.9%). Pre-transplant data were not available in many patients, including HCV genotype and serum HCV RNA level. Tacrolimus was more frequently used for initial maintenance immunosuppression than cyclosporine A (61.7% vs. 36.8%). Post-transplant HCV treatment was performed in 135 patients (48.7%). Sixty-seven recipients (24.2%) died during follow-up after LT and 11 HCV-related graft loss (4.0%) developed. The cumulative patient survival rate was 74.7% at 5 years and 67.9% at 10 years after LT. CONCLUSIONS: The HCV management protocol after LT varied markedly between the eight Korean transplant centers and a standard protocol did not exist. A nationwide multicenter study is required to investigate the most effective treatment for HCV after LT, with the goal of establishing the most effective standard protocol.

The Effect of Adjuvant Radiotherapy in Patients Undergoing Complete Resection for Gallbladder Cancer with Lymph Node Metastasis

PURPOSE: We evaluated the effect of adjuvant radiotherapy on survival in patients who underwent curative resection for gallbladder cancer with lymph node metastasis. METHODS: Among the patients underwent curative resection even though there was lymph node metastasis; fifteen patients underwent adjuvant radiotherapy with over 40 Gy (RTx group) and 10 patients did not (no RTx group). We compared these two groups retrospectively. RESULTS: The median disease free survival (DFS) of the RTx group (21.6 months) was longer than for the no RTx group (6.6 months, p=0.451). The median overall survival (OS) of the RTx group (30.5 months) was also longer than the no RTx group (14.2 months). One-, 2-, and 5-yr OS rates were 60.0%, 40.0% and 40.0% in the no RTx group, and 86.7%, 70.9% and 26.6% in the RTx group, respectively (p=0.507). Five patients developed recurrence within 1 year (50.0%) in the no RTx group; there were 3 (20.0%) in the RTx group. CONCLUSION: Our study was limited by its retrospective nature and small numbers of patients. However, it suggests that adjuvant radiotherapy might improve DFS and OS for patients with completely resected but lymph node metastasized gallbladder cancer. Also this therapy seems to delay time to postoperative recurrence.

Is Preoperative Chemotherapy Safe for Patients with Colorectal Liver Metastases Undergoing Metastasectomy?

PURPOSE: Controversies regarding preoperative versus postoperative chemotherapy for patients having hepatic metastases of colorectal primary made us elucidate the safety of chemotherapy. By examining the histopathologic changes in the liver following preoperative chemotherapy and analyzing the relation between surgical outcomes and preoperative chemotherapy, we were able to answer whether preoperative chemotherapy is safe. METHODS: We analyzed 38 patients who underwent chemotherapy before resection of hepatic metastasis from colorectal primary, retrospectively. Types of chemotherapy regimen were FL (5-FU+leucovorin), FOLFOX4 (oxaliplatin+5-FU+leucovorin), and FOLFIRI (irinotecan+5-FU+leucovorin). Results of liver function tests were compared before and after preoperative chemotherapy. One pathologist reviewed the degree of hepatic injury from resected specimens. Associations between the histological findings of hepatic injury and surgical outcomes and chemotherapeutic agents were examined. RESULTS: Histopathologic analysis revealed severe liver injury was present in 12 patients (31.6%). In further detail, moderate to severe sinusoidal dilatation was found in 3 patients (25%), steatosis of more than 30% was identified in 9 patients (75%), and steatohepatitis Kleiner score of > or =4 in 5 patients (41.7%). Preoperative chemotherapy did not affect the biochemical profiles of liver function. The overall perioperative complication rate was 5.3% (n=2). There was no difference in postoperative morbidity or mortality from reported results following hepatectomy. CONCLUSION: We found preoperative chemotherapy definitely induced histopathologic changes of hepatotoxicities. Even so, preoperative chemotherapy did not increase morbidity or mortality after hepatic metastasectomy. Preoperative chemotherapy seems to be safe in performing curative hepatic resection for the metastases.