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.

The Feasibility of Fundal Retraction of the Gallbladder in the Single Port Laparoscopic Cholecystectomy: Comparison between a 4-instrument Fundal Retraction Group and a 3-instrument Group

PURPOSE: Owing to the accumulation of surgical experience, the indications of single port laparoscopic cholecystectomy (SLC) have increased. To overcome the difficulties and limitations of SLC, we included an additional instrument for use in retracting the gallbladder fundus. The aim of this study was to investigate the feasibility of 4-instrument fundal retraction SLC. METHODS: We retrospectively analyzed 134 patients who had undergone SLC for benign gallbladder disease. We compared the clinical outcome between patients who had undergone SLC without fundal retraction (3-instrument SLC, n=102) and those who had undergone SLC with fundal retraction (4-instrument fundal retraction SLC, n=32). RESULTS: Of 134 patients, 47 were male and 87 were female. A significantly higher proportion of patients in the 4-instrument fundal retraction group had gallbladder distention and wall thickening than patients in the 3-instrument SLC group. No statistically significant difference in the incidence of pericholecystic inflammation, adhesion, and gallbladder perforation; duration of operation, the incidence of complications, and duration of postoperative hospital stay was observed between the two groups. In univariate analysis to perform 4-instrument fundal retraction SLC, higher BMI, the presence of gallbladder distension, and wall thickening were significant factors. In multivariate analysis, gallbladder distention and the presence of concurrent operation during SLC were independently significant factors for performing 4-instrument fundal retraction SLC. CONCLUSION: Four-instrument fundal retraction SLC is a feasible and safe surgical procedure, particularly in patients with a high BMI, gallbladder distention, wall thickening, inflammation, or adhesions. If difficulties are encountered during 3-instrument SLC, simple fundal retraction using an additional instrument may be the preferred option prior to converting the operation to conventional laparoscopic cholecystectomy.

Influence of metabolic and other clinicopathologic factors on the prognosis of patients with hepatocellular carcinoma undergoing hepatic resection

BACKGROUNDS/AIMS: The prognosis of hepatic resection for hepatocellular carcinoma (HCC) in patients with cirrhosis is worse than in those without cirrhosis. In Korea, the hepatitis B virus prevalence rate is higher than in other countries. Therefore, we investigated patients' clinicopathologic and metabolic factors that affect the postoperative outcomes of hepatic resection for HCC in our hospital in Korea. METHODS: From August 2000 to December 2012, 171 HCC patients underwent hepatic resections at our institution. Two operative mortality cases and two short-term follow up cases were excluded. Data was collected from a retrospective chart review. There were 133 males (79.6%) and 34 females (20.3%), with a mean age of 58.2+/-10.2 years (range, 22-81 years), and the relationship between clinicopathologic and metabolic factors and the prognosis of patients with HCC undergoing hepatic resection were evaluated by univariate and multivariate analysis. RESULTS: Hypertension, major surgery, perioperative transfusion, resection with radiofrequency ablation (RFA) or cryoablation, and resection margin were risk factors for overall survival, and hypertension, albumin, resection with RFA or cryoablation, perioperative transfusion, and tumor size were risk factors for disease-free survival. CONCLUSIONS: We found that hypertension, perioperative transfusion, and resection with RFA or cryoablation were risk factors for both disease-free and overall survival after hepatic resection in HCC patients. Further study is required to clarify the influence of metabolic and other clinicopathologic factors on the prognosis of HCC.

Balanced approach can help initial outcomes: analysis of initial 50 cases of a new liver transplantation program in East Asia

PURPOSE: To evaluate patient triage pattern and outcomes according to types of liver transplantation as part of a new liver transplant program developed in an East Asian country with a limited number of deceased donors. METHODS: Medical records of initial 50 liver transplantations were reviewed retrospectively. RESULTS: Twenty-nine patients underwent deceased donor liver transplantation (DDLT) and 21 patients underwent living donor liver transplantation (LDLT). Mean model for end-stage liver disease scores of recipients of DDLT and LDLT were 24.9 +/- 11.6 and 13.1 +/- 5.4, respectively (P < 0.0001). Twenty-eight patients had HCCs and 17 of them (60.7%) underwent LDLT, which was 80.9% of LDLTs. There were 2 cases of perioperative mortality; each was from DDLT and LDLT, respectively. Median follow-up was 18 months. Overall patient and graft survival rates at 6 months, 1 and 2 years were 95.7%, 93.4%, and 89.8%, respectively. There was no significant difference in survival between DDLT and LDLT. Overall recurrence-free survival rates of hepatocellular carcinoma (HCC) patients at 6 month, 1, and 2 years were 96.3%, 96.3%, and 90.3%, respectively. There was no significant difference in recurrence-free survival between DDLT and LDLT. CONCLUSION: As a new liver transplant program with limited resource and waiting list, patients with critical condition could undergo DDLT whereas relatively stable patients with HCCs were mostly directed to LDLT. We recommend a balanced approach between DDLT and LDLT for initiating liver transplant programs.

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.

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

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.

Comparisons of Oxidative Stress during Laparoscopic Cholecystectomy and Open Cholecystectomy

PURPOSE: During oxidative stress, the levels of oxygen free radical increase dramatically, which plays a role in apoptosis, aging and is chemic injury, but also leads to positive effects such as induction of host defense genes and mobilization of ion transport systems. It has been suggested that the advantages of laparoscopic surgery are closely related to the reduced oxidative stress that occurs during laparoscopic cholecystectomy (LC) when compared to open cholecystectomy (OC). This study was conducted to compare oxidative stress markers including total antioxidant status (TAS), superoxide dismutase (SOD) and gluthathione reductase (GR) between the LC group and OC group to determine if these surgical procedures result in different patterns of oxidative stress. METHODS: Our prospective study included fifty patients with symptomatic cholelithiasis and cholecystitis, of whom 25 underwent LC and 25 underwent OC. The plasma levels of oxidative stress markers (TAS, SOD, and GR) were measured preoperatively and on the 1st, 2nd and 3rd postoperative days. RESULTS: The postoperative hospitalization days differed significantly between the two groups (p0.05). An acceptable postoperative decrease in SOD was observed in the OC group, especially after the 2nd postoperative day (p0.05) upon analysis of covariance. A significant postoperative decrease in the level of SOD was observed in the OC group, especially after the 2nd postoperative day (p<0.01), and there was also a significant difference in the serial change in SOD between groups (p=0.020). The level of GR in the OC group decreased significantly on the 2nd postoperative day (p=0.022). Moreover, ANCOVA revealed a significant difference in the serial changes in thelevel of GR between the two groups (p=0.039). CONCLUSION: Our study compared oxidative stress between LC and OC groups based on the levels of TAS, SOD, and GR. We found that minimally invasive surgery, such as laparoscopic cholecystectomy, produced less oxidative stress than open surgery.

Laparoscopic Appendectomy: A Safe Procedure that can be Performed by Surgical Residents

PURPOSE: Although laparoscopic surgery has many advantages and has become popular in various disease settings, surgical residents do not yet have sufficient opportunity to perform laparoscopic surgery. Appendectomies are the most common procedures performed by surgical residents, and they may be suitable for gaining them laparoscopic experience. We had our residents perform laparoscopic appendectomies and analyzed clinical outcomes to verify the utility of this procedure in providing laparoscopy education. METHODS: Between September 2006 and December 2007, 384 patients with a preoperative diagnosis of acute appendicitis underwent laparoscopic appendectomy (n=191, LA) or open appendectomy (n=193, OA). Patient demographic data and outcomes for the two groups were compared. In the LA group, cases performed by surgical residents were compared against those performed by surgical specialists. RESULTS: Both groups of patients were comparable demographically. The incidence of complicated appendicitis in the LA group was 19.4% and that in the OA group was 25.9% (P=0.126). Operative time was similar between the two groups. Postoperatively, recovery time was shorter in the LA group than in the OA group, especially for patients with non-complicated appendicitis. LA performed by surgical residents showed similar outcomes, including operative time and postoperative recovery parameters. CONCLUSION: Laparoscopic appendectomy appears to have many advantages, such as less pain, rapid postoperative recovery, and more economic differential diagnosis. This procedure can be performed safely by surgical residents. Thus, laparoscopic appendectomy is a suitable procedure for laparoscopic surgery education for surgical residents.

A Comparative Study of Pancreaticoduodenectomy for Benign and Malignant Disease

PURPOSE: The mortality and morbidity rate after pancreaticoduodenectomy (PD) is still high, although the operative techniques and skills and the perioperative care has been improved. The incidence of PD for benign disease is 5~20%. The aim of this study is to determine the factors that differentiate between the benign group and the malignant group by comparing the clinical manifestations, and we studied the safety of performing PD for benign diseases by observing the early and late postoperative complications. METHODS: We retrospectively studied 124 patients who had been diagnosed with benign or malignant pancreatic diseases and who underwent PD between April 1995 and December 2005. We divided the patients into two groups, i.e., the benign group (20) and the malignant group (104), to compare their clinical characteristics and postoperative outcomes. Result: Chronic pancreatitis was the most common disease (35%) in the benign group and distal CBD cancer was the most common disease (40.4%) in the malignant group. Jaundice, weight loss, and elevation of CA 19-9 were more frequent in the malignant group than in the benign group (p<0.05). There were no statistical differences in the mortality rate (10.0% vs 6.7%), reoperation rate (5.0% vs 4.8%), hospital stays (27.1 days vs 24.0 days), early complications (30.0% vs 44.6%) and late complications (22.2% vs 26.4%) between the two groups. There were no mortality and newly developed malignancy during 33.4 months of follow-up period in benign group. CONCLUSION: On the preoperative evaluation, jaundice, weight loss, and elevation of CA 19-9 were more frequent in the malignant group. The postoperative early and late complications showed no difference between the two groups and complication rate was generally favorable. Thus, PD can be performed safely for benign diseases that cannot be treated in a conservative fashion and also for other clinically suspicious malignant diseases.

Expression of p53 and Vascular Endothelial Growth Factor in Gastric Cancer; Usefullness as Clinical Significance

PURPOSE: Recent studies have indicated that the p53 tumor suppressor gene and vascular endothelial growth factor (VEGF) play an important role in the angiogenic process of tumors. In this study, the correlation of the expressions of p53 and VEGF and the clinical features in gastric cancer were investigated. METHODS: The expressions of p53 and VEGF in gastric cancer were determined using immunohistochemistry on 98 randomly selected gastric cancer patients that had received curative resection. RESULTS: The expression of p53 and VEGF were observed in 51% and 50% of tumors, respectively. A significant correlation was found between p53 expression and the tumor histological type (P=0.045). The higher the TNM stage, the higher the observed level of p53 expression. The p53 and VEGF expression stati coincided in 70.4% of tumors, with a significant correlation found between the p53 and VEGF stati. Significantly worse survival rates were found in p53-positive and VEGF-positive patients than in those that were p53-negative and VEGF-negative. CONCLUSION: The present results indicated that p53 and VEGF expressions are useful in predicting the prognosis of patients with gastric cancer.