Living donor liver transplantation for Patients with beyond Milan hepatocellular carcinoma

BACKGROUND: To find the patients who have a significant chance of cure with living donor liver transplantation (LDLT) among the patients suffering with beyond-Milan hepatocellular carcinoma (HCC), we retrospectively analyzed the tumor factors that could affect a good prognosis after LDLT for patients who suffer with beyond Milan HCC. METHODS: Between March 2005 and May 2007, 18 cases of LDLT for beyond Milan HCC were performed. None of the patients had preoperative radiological evidence of vascular invasion. Excluding the 3 cases of in-hospital mortality, we analyzed the survival, the disease-free survival and the prognostic factors for recurrence in 15 beyond Milan HCC patients. The mean follow-up period was 18.8degrees +/- 8.8 months (range: 4-34 months). RESULTS: The two-year survival and disease-free survival rates after LDLT were 61.7% and 31.1%, respectively, in 15 beyond-Milan patients. Among them, 9 patients had recurrence of HCC during follow-up. The one-year survival rate after tumor recurrence was 55.5%. An alphafetoprotein (AFP) level < 400 ng/mL, Edmonson-Steiner histology grade I and II and the presence of graft rejection were analyzed as the good prognostic factors of disease-free survival after LDLT for beyond-Milan HCC (p < .05). The patients with negative preoperative positron emission tomography (PET) findings (n = 5) showed a better prognosis than the PET-positive patients (n = 10) with statistical significance (p = .05). CONCLUSION: Allowing that HCC patients exceed the Milan criteria, we can find the potentially curable candidates for LDLT with using tumor biologic markers such as a serum AFP level < 400 ng/mL, negative PET uptake or low grade histology, as assessed by preoperative needle biopsy. Further investigation is needed to evaluate the relation between graft rejection and tumor recurrence after liver transplantation.

Use of a Postoperative Hepatic Arterial Embolization in Patients with Postoperative Bleeding due to Severe Hepatic Injuries

PURPOSE: Acute liver failure after massive partial hepatectomy is critical condition with high mortality. To prevent postoperative liver failure from being induced by a massive partial hepatectomy, many doctors do a minimal resection on the single lobe of the liver that might cause postoperative bleeding from the remaining ruptured parenchyma. The objective of this study was to assess clinical experience with postoperative hepatic arterial embolization to control bleeding from the remaining ruptured liver during the postoperative period. METHODS: This retrospective 4-year study was conducted from May 2002 to April 2006 and included consecutive patients who had sustained massive hepatic injuries and who had undergone a laparotomy, followed by postoperative hepatic arterial angiographic embolization to control bleeding. Data on the injury characteristics, the operative treatment and embolization, and the amount of transfused packed red cells (PRBC) were gathered and analyzed. In addition, data on the overall complications and survival rate were collected and analyzed. RESULTS: Every case showed severe liver injury, higher liver injury scaling grade IV. Only ten cases involved a ruptured bilateral liver lobe. A lobectomy was done in 6 cases, a left lobectomy was done in 3 cases, and a primary suture closure of the liver was done in 2 cases. Suture closure was also done on the remaining ruptured liver parenchyma in cases of lobectomies. The postoperative hepatic arterial embolizations were done by using the super-selection technique. There were some cases of arterio-venous malformations and anomalous vessel branches. The average amount of transfused PRBC during 24 hours after embolization was 2.36+/-1.75, which statistically significantly lower than that before embolization. Among the 11 cases, 9 patients survived, and 2 died. There was no specific complications induced by the embolization. CONCLUSION: In cases of postoperative bleeding in severe hepatic injury, if there is still a large amount of bleeding, postoperative hepatic arterial embolization might be a good therapeutic option.

A Case of Postpneumonectomy Syndrome Treated with Endobronchial Stent / 결핵

Postpneumonectomy syndrome is a rare complication that usually occurs in younger patients within the first year after a right total lung resection. Its clinical presentations are stridor, dyspnea, and recurrent pulmonary infections. An airway obstruction secondary to the extreme mediastinal shift and rotation after a pneumonectomy is the main mechanism. It is commonly complicated with tracheobronchomalacia due to longstanding airway compression. The management modalities involve a repositioning of the mediastinum with volume expansion of the pneumonectomy site by a expandable prosthesis. however, other methods including an endobronchial stent insertion should be considered in the presence of a tracheobronchomalacia or in poor surgical candidates. Here we describe a case of postpneumonectomy syndrome complicated by a bronchomalacia, which was successfully treated with a self-expandable endobronchal stent.

MRI as a Preoperative Single Imaging Test in Hepatocellular Carcinoma / 한국간담췌외과학회지

BACKGROUNDS/AIMS: MRI performed preoperatively for Hepatocellular Carcinoma(HCC) not only detects and provides information on the tumor characteristics but can also be used as a noninvasive method via MR-angiogram. MR-angiogram can reconstruct the tumor and its relation to vessels in three dimension. Therefore, it has the advantage of presenting the exact relations of the tumor and the intrahepatic vessels. Recently, preoperative imaging in HCC has become more complex. The invasive angiography is at the center of these various, complex tests and there is a tendency for unnecessary, repeated testing. The cost of these complex tests is hard to ignore. The purpose of this study was to compare single preoperative MRI with other tests and weigh the advantages. METHODS: The subjects were thirty-nine patients who underwent surgery for HCC from November, 1997 through October, 1998. Ten of these patients who had HCC with the diameter of less than 5cm, were evaluated with MRI and when necessary MR angiogram only. The control group were eleven patients with tumor of the same size as above but whom were evaluated with abdominal CT + Hepatic angiogram + Transcatheter arterial chemoembolization(TACE) + lipodol CT, abdominal CT + Hepatic angiogram + CT - AP + TACE + lipodol CT or abdominal CT + Hepatic angiogram + CT - AP + TACE during the identical period. RESULTS: The average cost of preoperative testing was lowest with MRI only. There were no deaths in either group and complication occured in one case of each group. Comparison of the duration of admission between these groups showed a statistically significant difference(p=0.003). The MRI only group with an average of 22.5 days and the control group of 30.8 days. This was due to shortening of the preoperative testing time. Another point worth noting is that patients who underwent MRI alone complained less of discomfort. CONCLUSION: MRI alone group was comparable to control group in providing of preoperative anatomical information. Not performing angiography did not increase risks technically during operation. The authors suggest that MRI as the single preoperative imaging test can be in alternative to the various preoperative imaging test.

Brachial Artery Approach for Outpatient Arteriography

PURPOSE: To evaluate the diagnostic usefulness of brachial approach arteriography for outpatients, withparticular regard to safety and image quality. MATERIALS AND METHODS: The angiographic findings and follow-upmedical records of 131 brachial approach arteriographies in 121 outpatients were retrospectively analysed. 5 Fpigtail catheters were used in 125 cases, and 5-F OCU-A catheters were used in three cases of renal arteriography,and three of upper extremity arteriography without catheter. RESULTS: Except for three cases of brachial arterypuncture failure, all procedures were performed successfully. One hundred and fifteen of 119 lower extremityarteriographies were visualized down to the level of the tibioperoneal artery. The non-visualized cases were threein which there was multiple obstruction at the distal common iliac artery and one with insufficient contrastamount due to renal failure. In four cases there were complications : two involved arterial thrombosis, one was anintramuscular hematoma, and one an A-V fistula. CONCLUSION: For outpatients, brachial approach arteriography canreplace the femoral approach. Its image quality is excellent, there are time-cost benefits, and the rate ofcomplications is relatively low.