Management of Biliary Problem in Dual Living Donor Liver Transplantation / 대한이식학회지

PURPOSE: For the safety of donor and recipient in living donor liver transplantation, Asan Medical Center had attempted dual living donor liver transplantation (DLDLT) for the first time in the world. But bleeding chance and biliary problem occurred twofold in DLDLT, because DLDLT was used dual grafts. We analyzed the clinical features, the diagnosis, and management of biliary problem in DLDLT. METHODS: We retrospectively analyzed the cases of 61 patients had undergone DLDLT between July 2003 and June 2004. The cases with biliary problem was diagnosed by serologic examination (glutamic oxaloacetic transaminase/ glutamic pyruvic transaminase/alkaline phosphatase/total bilirubin) and image study (computed tomography and hepatobiliary scan). RESULTS: Among 61 cases had undergone DLDLT, 19 cases had biliary problem included biliary stricture only (14 cases), biliary stricture and bile leakage (5 cases). The major clinical manifestations of biliary problem were fever (12 cases), asymptomatic and/or increased liver enzyme (7 cases). Among 19 cases with biliary problem, 18 cases showed image study positive and serologic examination positive and/or symptomatic findings, and 1 cases showed image study positive and serologic examination negative and asymptomatic findings. The treatments of biliary stricture were endoscopic (naso/retrograde) biliary drainage (4 cases), percutaneous transhepatic biliary drainage (17 cases). In cases of bile leakage, we treated intraabdominal fluid collection with operative management (1 cases) and conservative managements (4 cases). Mortality rate related with biliary problem was 0%. CONCLUSION: Systemic and active postoperative management in biliary complication can help patients to minimize economic loss and sequelae.

S4a+S5 with Caudate Lobe (S1) Resection as a Parenchyma-preserving Liver Resection for a Patient with Type IIIb Hilar Bile Duct Cance

The prognosis of hilar bile duct cancer has been improved by extensive curative resection, but massive hepatectomy can result in surgical and medical complications in high-risk patients. We report a case of type IIIb hilar bile duct cancer undergone S4a S5 with caudate lobe (S1) resection as a parenchyma-preserving hepatectomy. The operation was a modified type of Taj Mahal liver resection omitting parencymal transection between S4b and S8. Such an extent of hepatectomy combined with bile duct resection made 3 right and 3 left intrahepatic segmental duct openings, which were reconstructed as a whole at each side of transection plane after ductoplasty. The patient recovered uneventfully. Although surgical technique for S4a+S5+S1 must be more complex comparing with other anatomical hepatectomy, but it could be accepted as a safe curative resection for some selected patients with advanced hilar bile duct cancer, by which favorable recovery of the liver function may lead to prevention of postoperative complications. Comprehension to the anatomy of the intrahepatic ducts is a prerequisite for S4a+S5+S1 resection, thus we discussed it in detail.

Analysis for Influencing Factor of the Organ Procurement Rate in Brain Dead Donors / 대한이식학회지

PURPOSE: The number of patients waiting for organ transplantation continues to grow as technical and pharmacological advances increase the success rate of transplantation procedures, while organs are donated by few of the thousands of potential donors who die every year. The organ transplantation continues to be the best treatment for many end-stage diseases of the heart, liver, kidneys, and other organs. Many organ procurement failures have been attributed to a failure to identify patients with nonsurvivable central nervous system injury or disease as potential organ donors or failure to maintain a hemodynamic stability or failure to request consent for donation from next to kin. This study has been done for investigating the factors that influence the organ procurement rate in brain dead donors. METHODS: Of the 259 brain dead donors in the Asan Medical Center, from January 1991 to April 2003, 189 brain dead donors donated solid organs excluding conea. We retrospectively reviewed the medical records and the data of the transplantation center. A hemodynamic stability is defined as systolic blood pressure more than 90~100 mmHg with the use of low-dose vasopressor (dopamine less than 10microgram/ kg/min). RESULTS: From January 1991 to April 2003, the procurement rates of liver, heart, kidney and pancreas were 39% (n=75), 40% (n=76), 97% (n=184) and 17% (n=33), respectively. The procurement rates according to age were 26% in 50 years (n=11). The major. causes of death among potential organ donors were traffic accident (59%) and cerebrovascular events (33%). In traffic accident, the procurement rates of liver, heart, kidney and pancreas were 42% (n=47), 37% (n=41), 98% (n=109) and 16% (n=18), and in cerebrovascular events, 33% (n=21), 38% (n=24), 97% (n=61) and 19% (n=12). Multiple organs were donated in the hemodynamically stable donors. CONCLUSION: Aggressive resuscitation and hemodynamically stabilization of all brain dead donors are important factors that may increase procurement rates.

Prognosis of Patients with the Gallbladder Carcinoma Undergone Laparoscopic Cholecystectomy as an Initial Operation

PURPOSE: Laparoscopic cholecystectomy (LC) has become a standard procedure for treatment of benign gallbladder diseases. There has been a small proportion of gallbladder cancers (GBC) which were incidentally found in the LC specimen, and LC has been tried in some patients with suspected GBC. This study intended to analyze the prognosis of patients with GBC undergone LC and the outcome of extended re-operation. METHODS: From Jan. 1995 to Aug. 2001, the outcome of 59 GBC patients undergone LC initially were analyzed. 100 GBC patients undergone laparotomic resection were chosen as control group. CO2 inflation method was used for LC. RESULTS: The depths of cancer invasion in 59 patients were as following: pTis in 2 (3.4%), pT1a in 4 (6.8%), pT1b in 14 (23.7%), pT2 in 28 (47.5%), and pT3 in 11 (18.6%). Re-operation was carried out at average 14 days after LC in 25 (42%) patients. There was no recurrence in patients with pTis and pT1a GBC, but there were two recurrent cases in pT1b GBC (each case with and without re-operation). The survival rate of patients of pT2 GBC who underwent re-operation after LC was better than that of patients who underwent one-stage laparotomic resection, but this difference was not demonstrated in patients with pT3 GBC. CONCLUSION: We think that LC does not deteriorate the prognosis of patients with incidentally detected GBC if appropriate re-operation is carried out according to the cancer staging. However, there is some possibility of tumor cell spillage during LC, so laparotomy should be preferred to LC for patients with suspected GBC in preoperative assessment.