Outcomes of Pancreas Transplantation: Single-Center Experience in Korea / 대한내과학회지

BACKGROUND/AIMS: Pancreas transplantation (PT) as the ultimate treatment for insulin-dependent diabetes has been the subject of debate clinically. Marked improvements in patient and graft survival, and decreases in postoperative morbidity have been achieved due to technical refinements, improved immunosuppressants, and better postoperative management. Here, we report our 18-year experience with PT performed at our institute. METHODS: All recipients who underwent deceased donor or living donor PT between July 1992 and December 2009 were included. We reviewed the medical records, including operation records, progress, and laboratory findings during follow-up. Graft and patient survival were analyzed using the Kaplan-Meier method. RESULTS: In total, 119 cases of pancreas transplantation were performed between July 1992 and December 2009 at our institute. Indications for pancreas transplantation were type I diabetes in 93 (78.2%) patients and type II diabetes in 16 (13.4%) patients. The transplanted pancreas was obtained from a deceased donor in 108 cases (90.8%) and a living donor in 11 cases (9.2%). Median follow-up duration was 39.3 months posttransplantation (range 0~176 months). Overall graft survival rates at 1, 5, and 10 years were 81.6%, 63.4%, and 57.1%, respectively. Following the introduction of tacrolimus as an immunosuppressant in 1999, graft survival at 1, 5, and 10 years was 89.1%, 72.9%, and 66.2%, and overall patient survival at 1, 5, and 10 years was 93.0%, 86.0%, and 86.%, respectively. CONCLUSIONS: Considering the quality of life and long-term patient survival, PT is an effective treatment strategy in non-obese diabetic patients requiring insulin regardless of the type of diabetes.

Liver Retransplantation: The AMC Experience

PURPOSE: Although there has been recent progress in surgical techniques, such as perioperative management, immunosuppresive regimen and intervention radiology, a liver retransplantation remains as the only therapeutic option for patients with a failing liver allograft. The purpose of this study was to review our clinical experiences of liver retransplantation, performed at the Asan Medical Center. METHODS: Between August 1992 and March 2001, 400 cases of liver transplantations, including 331 in adults and 69 in pediatrics, were performed. Of the 331 adult cases, 10 cases of liver retransplantation, during the same period, were retrospectively analyzed. RESULTS: In the 331 cases of adult liver transplantation, 232 cases of living donor and 99 of cadaveric liver transplantations were carried out. The 331 adult cases also included 10 liver retransplantations. Therefore, the overall liver retransplantation rate was 3%. Primary non-function (PNF) was the leading cause of retransplantation. The conversion of living donor liver transplantation to a cadaveric liver retransplantation was the most common type of retransplantaion, with a cadaveric to cadaveric type the second most common. The in-hospital mortality was 40%. The causes of in-hospital mortality were hepatic artery pseudoaneurysm rupture, Aspergillus pneumonia, and multiple organ failure, initiated by jejuno-jejunostomy site bleeding and massive hepatic necrosis. CONCLUSION: In the current era of extreme organ shortage, retransplantation is the only therapeutic alternative for irreVersible graft failure, especially if the patient has no multiple organ failure (MOF) prior to the operation. Therefore, the careful selection of patients for a retransplantation is required. They should be given superurgent priority if the circumstances permit, and living donor liver transplantation (LDLT) offer a promising alternative.

Liver Transplantation for Hepatocellular Carcinoma

PURPOSE: Surgery remains the treatment of choice for a hepatocellular carcinoma (HCC) confined within the liver. When there is no underlying liver disease, resection is the preferred option. In cases of HCC with cirrhosis, impaired hepatic reserve often precludes safe resection. Recently, acceptable transplantation outcomes have been shown in selected HCC patients. The aim of this study was to review the results of liver transplantation for HCC at the Asan Medical Center. METHODS: 73 HCC patients were treated by liver transplantation between August 1992 and April 2001. There were 7 in-hospital mortalities. The mean age of the patients was 51 years. The period of the median follow-up was 22 months. By reviewing the patients' medical records, we investigated tumor size, and number, TNM stage, survival rates, and recurrences. Statistical analysis was performed using Statistica 5.1 and SPSS 9.0. RESULTS: Among 67 patients, 8 (12%) developed a tumor recurrence or distant metastasis following the liver transplantation. The 3 year and 5 year survival rate were 88 and 57%, respectively. There were 12 incidentalomas. The 1 year and 3 year disease free survival rates of 54 cases, with the exception of the incidentalomas, were 80 and 50%, respectively. There were no statistically significant differences in the survival rates between the groups, with and without preoperative TACE (P=0.70). Also, there were no statistically significant differences in the survival rates between cadaveric donor liver transplantations (CDLT) and living donor liver transplantations (LDLT). CONCLUSION: We assume that transplantation for HCC, in carefully selected patients, may be the solution to HCC in cirrhotic livers. If the donor safety with a LDLT can be ensured, its application to patients with cirrhosis and early HCC may be a solution to the donor shortage, which could improve the survival of this group of patients.

20 Adult-to-Adult Living Donor Liver Transplantations Using Dual Grafts / 대한이식학회지

PURPOSE: The major limitation of adult-to-adult living donor liver transplantation (A-A LDLT) is the adequacy of the graft size. As an alternative, dual grafts from two living donors can solve the problem of graft-size insufficiency and guarantee the donor safety in many occasions. The present study aims to introduce the usefulness of dual-grafts A-A LDLT by review of our single center experience. METHODS: After the first successful pediatric LDLT in December 1994 and A-A LDLT in February 1997, 392 LDLTs including 73 pediatric and 319 adult cases were performed at Asan Medical Center until December 2001. Among 319 A-A LDLTs, 20 recipients implanted dual grafts were retrospectively analysed from March 2000 to December 2001. RESULTS: The ratio of graft volume to standard liver volume of the recipients ranged from 46.6% to 78.9%. More than 50% of the standard liver volume of the recipients was implanted in 16 patients. There was acute rejection episode in two patients, which were responded by pulsed steroid therapy. There were 3 in- hospital mortality (<3 month posttransplantation). CONCLUSION: In LDLT, the donor safety is the major concern. Although the donor has a large right lobe of liver that is adequate as a graft for large-size recipient, the remaining left lobe of liver is sometimes too small to endanger the donor safety. In this circumstance, the donor cannot be accepted to donate his or her right or left lobe of liver. Dual grafts from two living donors can help to alleviate the problem of small-for-size graft and secure the donor safety.

Infection after Adult-to-Adult Living Donor Liver Transplantation / 대한이식학회지

PURPOSE: Living donor liver transplantation (LDLT) has become an evolving option to overcome the shortage of cadaveric donor organ in adults as well as in children. The purpose of this study was to determine the incidence, timing, sites, and risk factors of infection after adult-to-adult LDLT. METHODS: The authors performed 104 adult-to-adult LDLT in 103 patients during the period of February 1997 and December 1999. The major indications for transplantation were chronic hepatitis B (53), hepatocellular carcinoma (27), and fulminant hepatitis (10). Right hepatic lobe was used in 54 cases and left lobe in 50. Graft weight-to-standard liver volume of the recipient ranged from 28.91% to 77.43% (mean 47.60%). No patient died during surgery. The incidence, timing, sites, and risk factors of infection after adult- to-adult LDLT were investigated retrospectively. RESULTS: A total of 114 cases of infection, including 85 bacterial, 3 mycobacterial, 16 fungal and 10 viral infection, developed in 65 (63.1%) patients. Seventy-one cases of infection occurred within 1 month after surgery. Intra-abdominal infection (31), hepato-biliary infection (19), primary bacteremia (12), and pneumonia (10) were the frequent ones, which developed mainly within 1 month after transplantation. Eight of 9 patients with pneumonia that developed early in the postoperative course died. Since January 1999, the incidence of pneumonia declined significantly from 20.0% (7/35) to 2.9% (2/68). Most fungal infection, including 7 cases of intra-abdominal infection, also occurred within 1 month after surgery (13/16). In contrast, all the 10 cases of viral infection developed after 2 months postoperatively. One case each of recurrent hepatitis B, recurrent hepatitis C, and posttransplant lymphoproliferative disorder died. Patients with infection showed significantly lower survival rate than those without infection (66.2% vs. 97.4%, p=0.0009). The indication for transplantation, amount of intraoperative RBC transfusion, and value of prothrombin time at the 7th day after surgery were significant risk factors for early serious infection on multivariate analysis. Urgency of operation was the only significant risk factor for early fungal infection on univariate analysis. CONCLUSION: For the prevention of early serious infection after liver transplantation, efforts to reduce the amount of intraoperative transfusion and to protect the graft from perioperative insults should be executed. Preemptive anti-fungal therapy is suggested in cases of emergent operation.

Safety of Donor in Adult-to-Adult Living Donor Liver Transplantation

PURPOSE: Right lobe donation was advocated to overcome size-mismatch between left lobe and larger-size recipient in living donor liver transplantation (LDLT), however, safety of donor is a major concern. The purpose of this study is to evaluate the safety of donor in adult-to-adult LDLT. METHODS: Retrospective analysis of 104 adult-to-adult LDLT was performed by comparison of left lobectomy (n=50) and right lobectomy (n=54) groups. RESULTS: The median age of donors was 28 years and offsprings were most common donors (33.7%). The right lobe graft provided larger mass by 60% than left lobe. The ratio of residual liver volume to total liver volume, operation time, intraoperative blood loss, and postoperative ICU stay showed significant differences in both groups. Recovery of liver profiles was delayed by several days in right lobectomy group, but all donors recovered uneventfully. There was no mortality nor sequela in both groups. Severe postoperative complications occured more frequently in right lobectomy group, and they were bile leakage (n=3), postoperative bleeding (n=5), and portal vein thrombosis (n=1). All complications were controlled with safety. CONCLUSION: Right lobe harvesting can be safe but should be performed only by expert operators because there is potential operative risk. To minimize operative complications, attention should be paid to every step of procedures and to postoperative surveillance.

A Comparison of Open and Laparoscopic Cholecystectomy for Patients with Liver Cirrhosis / 한국간담췌외과학회지

BACKGROUNDS/AIMS: Cholelithiasis is a prevalent diseases worldwide and it is known that its incidence is twice as common in cirrhotic patients compared with noncirrhotic patients. Liver cirrhosis is a critical factor contributing to morbidity and mortality in biliary tract surgery, as patient with cirrhosis are at particular risk of developing bleeding, infection and intractable ascites. Recently laparoscopic cholecystectomy has become the procedure of choice for cholelithiasis in the general population. This retrospective study was conducted to assess the effective treatment by comparing the results of open cholecystectomy versus laparoscopic cholecytectomy in cirrhotic patients. METHODS: Between January 1991 and December 1998, 53 patients with liver cirrhosis underwent cholecystectomy for cholelithiasis in the department of surgery at asan medical center. The patients were classified into two groups: one consisting of 18 patients who underwent open cholecystectomy and another consisting of 35 patients who underwent laparoscopic cholecystectomy. All cases that converse to an open cholecystectomy from a laparoscopic cholecystectomy were excluded from this analysis. RESULTS: No statistical difference was observed in the duration of surgery(OC: 110.6+/-32.6 vs. LC: 82.1 +/-26.7 min, p>0.05). Laparoscopic cholecystectomy was followed by a significantly smaller intraoperative blood loss(OC: 730.5+/-384.6 vs. LC: 324+/-168 ml, p<0.05), a earlier resumption of a normal diet(OC: 4.3+/-1.3 vs. LC: 1.3+/-0.4 days, p<0.05), and a shorter hospital stay(OC: 13.8+/-6.1 vs. LC: 4.7 +/-2.1 days, p<0.05) in comparison to open cholecystectomy. Postoperative complications in laparoscopic cholecystectomy group was significantly less(OC: 9 vs. LC: 4, p<0.05). There was no operative mortality in both group. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in compensated cirrhotic patients and may be the procedure of choice whenever cholecystectomy is indicated in a cirrhotic patient because it may be associated with more advantages.

Long-Term Results of a Hepatopancreatoduodenectomy for Biliary-Tract Cancer

PURPOSE: The majority of carcinomas of the biliary tract are often diagnosed at an advanced stage, despite improved diagnostic capabilities. Aggressive surgery is generally recommended in an attempt to cure the advanced disease because only complete resection of the tumor can provide a chance to improve the survival rate. Thus, the purpose of this research was to assess the effectiveness of a hepatopancreato duodenectomy (HPD) in patients with both advanced gallbladder cancer directly invading adjacent organs and diffuse bile-duct cancer by analyzing the long term results of an HPD. METHODS: Forty patients underwent an HPD at Asan Medical Center from December 1993 to May 1999, and their cases were retrospectively reviewed. Gallbladder cancers was present in 14 of the patients and bile-duct cancers in 24 cases; the other 2 cases were benign. Cancers were classified by using the criteria of the American Joint Commission on Cancer (AJCC). Survival curves were calculated by using the Kaplan-Meier method. The median follow-up was 35 months. RESULTS: Hepatectomies varied from a right trisegmentectomy to an S4aS5 subsegmentectomy. There were 19 (47.5%) major postoperative complications, including intraabdominal bleeding, intestinal obstruction, liver abscess, and others. Of the 14 patients experiencing tumor recurrence, 7 (50%) cases involved the remnant liver. There were 4 (10%) perioperative mortalities. The 5 (22.7%) patients who with stage IVa and IVb cancer (22 cases) survived more than 3 years are all still alive and without tumor recurrence. The 1-and 3-year cumulative survival rates for gallbladder cancer were 83.3% and 48.5%, respectively, and those for bile-duct cancer were 83.3% and 49.7%. The differences in survival between the groups was not statistically significant, excluding perioperative deaths. The median survival was 13.7 months. CONCLUSION: An HPD is indicated for either advanced gallbladdercancer or diffuse bile-duct cancer because complete resection through this surgical procedure can provide a chance to improve survival. It is necessary to decrease perioperative mortality and morbidity by complete preoperative evaluation, meticulous operative manipulation, and intensive postoperative care.

Results of Use of Hepatitis B Core Antibody-Positive Donors in Living Donor Liver Transplantation with Passive Immunoprophylaxis / 한국간담췌외과학회지

BACKGROUND: In Korea, the number of patients enrolled in liver transplantation registry exceeds the supply of cadaveric donor. This donor shortage leads to living donor liver transplantation(LDLT). Due to wide prevalence of hepatitis B in Korea, many healthy donors for LDLT shows hepatitis B surface antigen-negative[HBsAg(-)] and core antibody-positive [HBcAb(+)]. However, the risk of using graft livers from HBsAg(-) and HBcAb(+) donors has not been clearly defined. The aim of this study is to identify the safety of using HBcAb(+) donor and the effectiveness of passive immunoprophylaxis with hepatitis B immunoglobulin(HBIG) in non-hepatitis B virus induced cirrhotic recipients. METHODS: From December 1994 to July 1998, 59 patients underwent living donor liver transplantation at the Asan Medical Center. Among them, 35 cases were non-hepatitis B virus induced cirrhotic recipients. Of these 35 recipients, 14 patients received liver graft from HBsAg(-) and HBcAb(+) donors and prophylactic passive immunoprophylaxis with HBIG. RESULTS: Eleven cases remained HBsAg(-) with HBIG immunoprophylaxis. Three of 14 recipients who were HBsAg(-) converted to HBsAg(+) serologically after receiving HBcAb(+) donor liver. All of these 3 cases did not receive HBIG therapy. CONCLUSIONS: Passive immunoprophylaxis with HBIG may prevent non-hepatitis B induced cirrhotic recipients from converting to HBsAg(+) status by using HBcAb(+) donor. Our experience suggests that HBcAb(+) donors can be accepted as potential donors in living donor liver transplantation.

Techniques and Indications for a Central Bisegmentectomy of the Liver

BACKGROUND: Central bisegmentectomy (CBS) of the liver is a resection of the medial and anterior segments for preserving more liver parenchyma and reaching the goal of a curative resection simultaneously. PURPOSE: In this paper, we describe the indications and the techniques for this surgical procedure. PATIENTS AND METHODS: We reviewed the case histories of 14 patietns who had undergone a CBS, including 9 with a hepatocellular carcinoma, 4 with hilar bile-duct cancer, 1 with metastatic colon cancer, and 1 with gallbladder cancer. Eight patients had undergone a CBS with an operating time of only 353 minutes; 5 cases had undergone a CBS and a caudate lobectomy plus bile-duct resection, requiring an operating time of 762 minutes. A hepaticojejunostomy to right posterior hepatic duct was added to one CBS case because of intrahepatic ductal variation. The surgical technique for the CBS only procedure was as follows: demarcation of the dissection line with a selective block of the glissonian cord, division of the medial and the lateral segments along the falciform ligament to expose the left hepatic vein, and division of the anterior and the posterior segments along the right hepatic vein. In the combined bile-duct-resection cases, complete dissection of the hepatoduodenal ligament and biliary reconstruction were added. RESULTS: The extent of liver resection, as estimated by CT volumetry, was about 42%, and the mean value of the real weights of the specimens was 474 gm. The preoperative hepatic function showed a 9.3% indocyanine-green retention rate at 15 minutes, and 5 out of 9 hepatocellular carcinoma cases revealed concomitant liver cirrhosis. For CBS and additional procedures, the curative resection rate reached 93%, and the survival rate was favorable. There were no operative mortalities or hepatic failures. CONCLUSIONS: For selected cases of centrally located liver tumors or hilar bile-duct cancer with limited hepatic reserve, CBS may provide a safe, curative resection.

Prognosis for a Hepatocellular Carcinoma Smaller Than 5 cm in Relation to Hepatic Resection: Major Resection vs Limited Resection

BACKGROUND: A hepatocellular carcinoma (HCC) is an awesome malignancy; survival time is usually less than 1 year once symptoms and signs appear, irrespective of treatment. Screening tools are now available that make it possible to detect a preclinical HCC, which is usually small and surgically resectable. We studied the prognosis after hepatic resections of HCCs smaller than 5 cm and tried to clarify which effective treatments correlated with high survival rates by comparing the outcomes of major hepatic resections with those of limited hepatic resections. METHODS: Of the 105 cases treated from January 1, 1990, to December 31, 1998, at Asan Medical Center, all proved surgically to be small HCCs and pathologically to be HCC types. There were two categories of patients: those receiving a major hepatic resection (n=48) and those receiving a limited hepatic resection (n=57). RESULTS: The median age was 53 (range, 33-69), and the male:female ratio was 42:6 in the major resection group. The median tumor size was 3.4 cm, and the median resection margin was 2.6 cm. Major resections were done in 48 cases, including right lobectomies (32 cases), left lobectomies (9 cases), central bisegmentectomies (3 cases), extended left lobectomies (3 cases) and extended right lobectomy (1 case). The median age was 52 (range, 30-76), and the male:female ratio was 46:11 in the limited resection group. The median tumor size was 3.2 cm, and the median resection margin was 1.2 cm. Limited resections were done in 57 cases, including left lateral segmentectomies (12 cases), right posterior segmentectomies (10 cases), #6 subsegmentectomies (7 cases), left medial segmentectomies (7 cases), right anterior segmentectomies (6 cases), nonanatomical partial hepatectomies (5 cases), #5 #6 subsegmentec-tomies (2 cases), #8 subsegmentectomies (2 cases), caudate lobectomies (2 cases), #5 subsegmentectomies (2 cases), #5 subsegmentectomy caudate lobectomy(1 case), and #2 subsegmentectomy (1 case). The cumulative 5-year survival rate of the two groups was 69%. The cumulative 5-year disease-free survival rate of the major resection group was better than that of the limited resection group (80% vs 53%, p=0.01). CONCLUSIONS: Problems, including the relatively high recurrence rate after a limited hepatic resection, remain to be solved. It is necessary to perform adjuvant therapy to prevent recurrence in patients receiving a limited hepatic resection. We advocate a major hepatic resection for primary small hepatocellular carcinomas in order to prevent recurrence. Preoperative portal vein embolization can be a good modality in patients who will undergo major hepatic resections.

Right Hepatic Lobectomy in the Treatment of Right-sided Hepatolithiasis

BACKGROUND: Right-sided hepatolithiasis has been diagnosed in 14-25% of all hepatolithiasis cases and right hepatic resection contributes only 5-9% of all hepatic resections for hepatolithiasis. Outcomes of otherwise treatment modalities were unsatisfactory resulting high incidence of remnant stone and high recurrence rate. General indications for hepatic resection in hepatolithiasis include localized intrahepatic calculi with irreversible biliary strictures, atrophied segment or lobe of the liver, multiple cholangitis abscess and possible presence of cholangiocarcinoma. PURPOSE: In this study, we presented the outcome of right hepatic lobectomy in right-sided hepatolithiasis patients, especially focused on the rationale and indications of this procedure. METHODS: We reviewed 15 cases undergone right lobectomy for right-sided hepatolithiasis from January 1995 to June 1997 with median follow-up of 23 months. RESULTS: Mean age of the patients was 49 years old. Clinical manifestations included signs of cholangitis in 7 (47%), abdominal pain in 5 (33%), jaundice in 1 (7%) and nonspecific symptoms in 2 (13%) cases. Criteria for indications of right lobectomy were overt biliary strictures in 9 (60%), marked atrophy of the right lobe in 7 (47%), multiple cholangitis abscess in 6 (40%) and suspected cholangiocarcinoma in 2 (13%) cases. Mean indocyanine green retention rate at 15 minutes was 7.6 4.5% and mean weight of resected specimen was 352 185 gm. Operative stone clearance rate was 100% for 14 isolated right-sided hepatolithiasis cases and choledochoscopic stone removal was followed for 1 both-sided case. Overall stone clearance rate was also 100%. Rate of stone recurrence was 0% at median follow-up of 23 months. Operative complications occurred in 4 cases without hepatic function-associated complication or operative mortality. CONCLUSIONS: Right hepatic lobectomy is indicated in patients who have localized right-sidedhepatolithiasis with irreversible biliary strictures involving the right hepatic duct, an atrophied right lobe of the liver, multiple cholangitis abscesses, or possible presence of cholangiocarcinoma.

Right Hepatic Lobectomy for Adult Living Donor Liver Transplantation Safety, anatomical points, and technical points

BACKGROUND: Living related liver transplantation (LRLT) has gained acceptance as treatment modality for children with end-stage liver disease. The left lobe used in LRLT doesn't provide adequate parenchymal mass for its application to adults. We have used right lobe for LRLT in adults. Some criticism has been aroused becuase of the potential significant risk to the donors. METHODS: We analyzed the surgical risk and the stress to 20 donors in a right lobectomy for LRLT. We also analyzed anatomical points for safe harvest, and we describe techincal points based on anatomical variations. RESULTS: There were no deaths, and 6 major complications (3 bleeding, 1 perihepatic fluid collection, 1 pleural effusion, and 1 bile peritonitis after removal of the T-tube) occurred in 6 patients. Liver function was normalized within 2 weeks. There were anatomical variations in the hepatic vein, the portal vein, and the bile duct, especially the right inferior hepatic vein (55%), trifurcation of the portal vein (10%), low inserion of the right posterior bile duct into the common hepatic duct (10%), and separate insertion of the right anterior bile duct and right posterior bile duct into the hepatic duct (10%). We made a vena cava patch for the right inferior hepatic vein. In cases of the low insertion of the right posterior hepatic duct into the common hepatic duct, the cholecystectomy should be done carefully so as not to injure the right posterior hepatic duct. We ligated and divided the right posterior bile duct before dissection of the hepatic artery and the portal vein. In cases of trifurcation of the portal vein, closure of the left portal vein should be done to prevent the narrowing of the left portal vein lumen. CONCLUSIONS: Our results suggest that a right lobectomy for LRLT is safe for donors. However, anatomical variations in the bile duct, the hepatic vein, and the portal vein should be kept in mind to ensure a safe and successful operation.

Clinical Analysis of Anomalous Pancreaticobiliary Ductal Union

BACKGROUND: With improvements in the performance of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing hepatobiliary and pancreatic diseases, anomalous unions of the pancreaticobiliary duct (AUPBD) have come to our attention in recent years. Such unions are thought to be a factor in the development of carcinomas of the pancreaticobiliary system. The purpose of the present study was to evaluate the clinical analysis of AUPBD for proper treatment. METHODS: During the past 4 years from January 1, 1993, to December 31, 1997, 28 adult patients with AUPBD, in whom the pancreaticobiliary ductal union and terminal biliary tract were opacified by ERCP, were seen at Asan Medical Center. We divided the types of AUPBD according to Kimura's classification. RESULTS: The ages of the patients (20 women and 8 men) with this anomaly ranged from 16 to 68 years. The patients' main complaints were abdominal pain (16 cases), indigestion (10 cases), jaundice (4 cases), and fever (2 cases). The common channel measured on direct cholangiograms was 15 mm to 42 mm long. All of the patients whose anomalies were confirmed by ERCP had combined diseases (benign diseases 20 cases, malignant diseases 8 cases). Of the 20 patients with benign diseases, the 15 patients who underwent operative treatments had no recurrent findings or symptoms, but all of the 5 patients who underwent conservative treatments had recurrent pancreatitis or indigestion. These 5 patients will still need to be followed up. For the 8 patients with malignant diseases, the 3 who did not undergo operations died of far-advanced cancer. Among the remaining 5 patients who underwent operative treatments, 1 patient died of cancer recurrence, but 4 patients have been alive since their operations. CONCLUSIONS: We think that all ERCP examinations have to be carried out with AUPBD in mind. It is important to remove the place that causes bile stasis and to stop backflow of pancreatic juice intothe bile duct in managing patients with this anomaly. Therefore, a prophylactic cholecystectomy and reconstruction of the biliary tract are both necessary in treating AUPBD.

Four Cases of Intrahepatic Biliary Cystadenoma and Cystadenocarcinoma

A biliary cystadenoma (BC) and a cystadenocarcinoma (BCA) are rare neoplasms of the liver. Among 178 patients with primary liver neoplasms who underwent surgery during the last two years at our department, there were only one case of BC and three cases of BCA. The BC case was a 57-year-old female with 15-cm-sized multilocular cystic mass containing mucin. That patient, who had undergone a simple excision of a liver cyst 6 years earlier under the diagnosis of a cystadenoma, received a repeated wedge resection and is still doing well, no recurrence, 41 months after the resection. One BCA case was a 59-year-old female with an 8-cm-sized multilocular cystic mass. She underwent an extended left lobectomy and is still alive, without recurrence, 55 months later. Another BCA case was 77-year-old female with multiple multilocular masses which had degenerated due to sclerotherapy; the masses were removed by a wedge resection. She has been alive 35 months without recurrence. The other BCA case was a 37-year-old female with a 10-cm-sized unilocular mass with lung metastasis. She underwent an extended left lobectomy and survived 22 months. Malignant transformation of a BC to a BCA is well documented, and recurrence is the rule following incomplete resection. Complete resection of a BC and radical resection of a BCA seem to offer a chance for long-term survival.

Report of a Child Donors Liver Transplanted into an Adult Recipient

Under normal circumstances, attempts are made to match the recipient of an orthotopic liver transplant with the best available donor in terms of organ and body size. Occasionally, it may happen that a child's liver is transplanted into an adult recipient, either because of the need for an urgent transplantation when only a small donor is available or because there is no child recipient transplantable with the graft. After a child-donor's liver was transplanted into an adult recipient, we had the opportunity to observe the change in the size of the allograft over time by using serial computed tomography scans to evaluate change in graft size. Reported here are the results of the small-for-size live transplantation at Asan Medical Center.

Anterior Segment Congestion of a Right Liver Lobe Graft in Living Donor Liver Transplantation and its Strategy to Prevent Congestion / 대한이식학회지

PURPOSE: A left lobe graft from a small donor will not meet the metabolic demands of a larger recipient in adult-to-adult living donor liver transplantation (LDLT). One solution to this problem is to use a right lobe graft. However, the necessity of the middle hepatic vein (MHV) drainage from the anterior segment of a right lobe graft was not yet clearly described in the literatures. METHODS: From July 1997 to February 1998, five right lobe grafts without having a MHV drainage were implanted in 5 recipients with 2 HBV-cirrhosis, 2 fulminant hepatic failure and 1 secondary biliary cirrhosis. The graft weight ranged from 650 gm to 1000 gm, and their volume ranged from 48% to 83% of the ideal liver mass of the recipients. RESULTS: Two grafts showed severe congestion of the anterior segment immediately after reperfusion, followed by prolonged massive ascites and severe liver dysfunction in each patient postoperatively. Eventually, one patient died of sepsis on posttransplant 20th day demonstrating progressive hepatic dysfunction. CONCLUSION: A right lobe graft without having MHV drainage might result in severe congestion of the anterior segment, which was able to lead to the patient's death in an extreme situation. Preservation of the anterior segment venous drainage in the right lobe graft is possible by two harvesting method: an extended right lobe (ERL) graft in which MHV is included in the graft and a modified right lobe (MRL) graft in which venous tributaries of the anterior sement were reconstructed via interposition vein grafts into the recipient's hepatic venous system. Theoretically, in a view point of donor safety, a MRL graft is more advantageous than an ERL graft because MHV is left in the donor liver. Here, we report our experiences of 27 MRL grafts in adult-to-adult LDLTs.

Experience with a Retroperitoneoscopic Adrenalectomy: A report of 16 cases

BACKGROUND: The laparoscopic adrenalectomy has become the standard procedure of adrenal surgery owing to its advantage of minimally invasive surgery and to rapid developments in the laparoscopic technique and apparatus. A posterior retroperitoneoscopic adrenalectomy is a new alternative to both the conventional open approach and a transperitoneal laparoscopic adrenalectomy. This technique is known to be technically difficult and is less frequently done than a transperitoneal laparoscopic adrenalectomy. However, recently, a number of acceptable results have been reported for this procedure. GOAL: We report our experience with and the results from 16 cases involving a retroperitoneoscopic adrenalectomy and evaluate the advantages and disadvantages of this technique. MATERIALS AND METHOD: Between November 1996 and November 1997, a total of 16 retroperitoneoscopic adrenalectomies were performed. All 16 cases had unilateral adrenal tumors(size 1.5-6 cm): 8 Conn adenomas, 4 Cushing adenomas, 2 neurogenic tumors, 1 nonfunctioning adenoma, and 1 vascular cyst. The operations were carried out in the prone position in all cases. Three trochars were inserted below the lower posterior costal margin. The balloon dilatation technique with a surgical globe was used to induce pneumoretroperitoneum in the first 10 cases but in the last 6 cases, the cavity was made only by blunt dissection with the scope and laparoscopic dissector. RESULTS: Fourteen adrenalectomies were completed endoscopically. One was converted to an open posterior approach due to severe skin emphysema and the other case was converted to an open anterior approach due to technical difficulty. The average operating time of the completed endoscopic adrenalectomies was 183 minutes (85-315 minutes) and the average time of the last 8 cases was 148 minutes. There was no operative morbidity or mortality. Immediate mobilization and food uptake was possible on the day of the operation in all cases. Postoperative analgesic injection was needed only one time on the day of the operation in 12 cases and was not needed in 2 cases. The average hospital stay was 4 days after the surgery.

Adult-to-Adult Living Donor Liver Transplantation

BACKGROUNDS: Living-donor liver transplantation (LDLT) has been established as an efficacious option to resolve the shortage of cadaveric donor organs for pediatric recipients. This surgical innovation has significantly reduced the pretransplantation mortality for children, but the crisis of increasing scarcity of donor organs in our hospital has led us to extend LDLT to adult recipients. However, the extension of LDLT from pediatric recipients to adult recipients has been made only with limited success largely because of the inability of a relatively small-size left-lobe graft to meet the metabolic demands of an adult recipient. It has been postulated that a left-lobe graft smaller than 40% of the recipient's standard liver volume will not result in a successful adult-to-adult LDLT in chronic parenchymal liver disease. METHODS: From February 1997 to October 1997, 10 LDLTs, using 9 extended left-lobe grafts and 1 right-lobe graft, were performed on patients with end-stage parenchymal liver diseases (9 cases of B-hepatitis-induced cirrhosis with or without an associated hepatocellular carcinoma and 1 case of alcoholic cirrhosis) at the Department of Surgery, Asan Medical Center. The ratios of the graft to the standard liver volume of the recipients were in the range of 30% to 55%. RESULTS: All grafts showed immediate function, but delayed normalization of the serum total bilirubin was demonstrated in all recipients receiving left-lobe grafts. There were no mortalities and serious complications in donors. Two recipients died of sepsis 21 days and 40 days after transplantation, and 8 recipients (80%) are alive with good liver function at a median follow-up of 5.1 months (range 2~10 months). CONCLUSIONS: The aim of this article is to report our experience with adult-to-adult LDLT shows that a graft size greater than 30% of the recipient's standard liver volume is able to meet the metabolic demands of adult recipients with chronic parenchymal liver disease and that LDLT might open a new donor pool for adult recipients when the supply of cadaveric organs is severely restricted.

Retroperitoneal Laparoscopic Lumbar Sympathectomy

Seven cases of retroperitoneal laparoscopic lumbar sympathectomy were successfully performed in 10 patients with ischemic lesions of lower limbs or ischemic rest pain between June, 1996 and October, 1996. All patients had nonreconstructable distal vessels on femoral angiogram. Our techniques of retroperitoneal laparoscopic lumbar sympathectomy is described in detail. Procedure offers the advantage of minimally invasive surgery and can be performed more efficiently as the experience of the surgeon accumulates.