Influence of anti-adhesive agent on incidence of bile leakage after liver resection: A prospective cohort study.

BACKGROUND: Anti-adhesive agents are increasingly used to reduce the incidence of postoperative adhesions following abdominal surgery. Bile leakage after liver resection remains a major cause of postoperative morbidity. The aim of this study was to examine the effect of anti-adhesive agent on bile leakage after liver resection. MATERIALS AND METHODS: 77 patients were enrolled to receive an anti-adhesive agent (study group) during liver resection between May 2012 and August 2013. The study group was compared to a match-paired control group. Clinical data were collected including bilirubin concentration in serum and drain fluid and bile leakage rate. In addition, a separate analysis was performed between patients with and without postoperative bile leakage. RESULTS: There was no difference in bile leakage rate or hospital stay between the study group (n = 77) and control group (n = 77). Of the total number of patients (n = 154), there were 29 patients with postoperative bile leak and 125 patients without bile leak. On univariate analysis, patients without history of hepatitis were significantly associated with bile leakage. In addition, liver resection with broader cut surface area was associated with bile leakage. Application of anti-adhesive agent was not associated with bile leakage. On multivariate analysis, resection with broader cut surface area (OR = 2.788, p = 0.026) and patients without history of hepatitis (OR = 5.153, p = 0.039) were significantly associated with bile leakage. CONCLUSIONS: Larger area of cut-surface and patients without history of hepatitis were significant risk factors for bile leakage. The use of anti-adhesive agent was not associated with increased risk of bile leakage.

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.

Disease recurrence patterns and analysis of clinicopathological prognostic factors for recurrence after resection for distal bile duct cancer.

Surgical resection is the treatment of choice for bile duct cancers. The aim of this study was to investigate disease recurrence patterns and prognostic factors for recurrence of distal bile duct cancers after surgical resection. A retrospective study was performed on 122 patients with distal bile duct cancers who underwent R0 or R1 surgical resection at Korea University Guro Hospital from 1991 to 2010. Sites of initial disease recurrence were classified as locoregional or distant. Univariate and multivariate analyses were performed to investigate the factors affecting recurrence. Of the 122 patients, 80 patients developed recurrence. The disease-free survival rate was 63.1 per cent at one year and 36.4 per cent at three years. The patterns of recurrence at diagnosis were locoregional in 25 patients, locoregional and distant metastasis in 14 patients, and distant metastasis in 41 patients. Multivariate analyses revealed that recurrence pattern, lymph node metastasis, and differentiation are independent prognostic factors affecting disease-free survival. R status (marginal significance) and tumor differentiation were independent prognostic factors associated with locoregional recurrence. Differentiation and lymph node metastasis were independent prognostic factors associated with distant metastasis. The prognosis after recurrence was poor with a 1-year survival rate after recurrence of 26.1 per cent. Adjuvant chemo- or radiation therapy, delivered in patients mainly with R1 resection or with presence of lymph node metastasis, did not demonstrate the survival benefit. Significant factors for recurrence were tumor differentiation and lymph node metastasis. Therefore, close follow-up and adjuvant therapy will be necessary in patients with lymph node metastasis or poorly differentiated tumor.

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.

Clinicopathological analysis and survival outcome of duodenal adenocarcinoma.

Duodenal adenocarcinoma is a rare cancer, contributing <10 % of periampullary carcinoma. This study reviews the single center experience of duodenal adenocarcinoma and analyzes the clinical and pathological factors to predict survival and recurrence. The records of 50 patients with duodenal adenocarcinoma who underwent surgical exploration or resection from 1995 to 2010 were reviewed retrospectively. Univariate and multivariate analyses were performed to identify the clinicopathological factors associated with survival and recurrence. There were 35 men and 15 women, with a mean age of 61 years. In multivariate analysis of 50 patients, R0 resection [p = 0.041, hazard ratio (HR) = 3.569, 95% confidence interval (CI) = 1.057-12.054] and symptom at initial admission (p = 0.025, HR = 11.210, 95% CI = 1.354-92.812) were independent prognostic factors for overall survival. Thirty-six patients underwent curative resection (resectability 72%). The 5-year survival rates for curative and noncurative resections were 46.4% and 0%, respectively. Univariate analysis of 36 patients who underwent R0 resection revealed that symptoms at initial admission (p = 0.023), presence of lymph node metastasis (p = 0.034), and perineural invasion (p = 0.025) were significant prognostic factors after curative resection. There was no significant factor for overall survival in the multivariate analysis. There was recurrence in 15 patients, mainly as liver metastasis. Multivariate analysis revealed that presence of symptom (p = 0.047, HR = 5.362, 95% CI = 1.021-28.149) and ulcerative tumor (p = 0.036, HR = 5.668, 95% CI = 1.123-28.619) were independent factors for disease free survival. An aggressive surgical approach to achieve R0 resection was important to enhance survival. Most of the recurrence occurred within 1 year after surgery. Close follow-up is necessary after surgical resection.

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.

Intraoperative Radiation Therapy for Gallbladder Cancer: Experience at a Single Institution.

BACKGROUND/AIMS: To investigate the survival outcome of intraoperative radiation therapy for patients with gallbladder cancer on the basis of experience at a single institution. METHODOLOGY: The medical records of 8 patients with gallbladder cancer who were treated with intraoperative radiation therapy during surgical resection or palliative surgery were retrospectively analyzed. The primary endpoint was overall survival. The median follow-up time was 20.8 months. RESULTS: The median survival time was 15.0 months. Overall survival for all patients was 75.0% at 1 year, 37.5% at 3 years, and 25.0% at 5 years. Three patients underwent complete resection, and 5 patients had residual tumor after resection or palliative surgery. The 3-year OS rate for 3 patients with no residual tumor after curative resection was 66.7%, with a mean survival time of 122.6 months, whereas the 3-year OS rate for 5 patients with macroscopic residual diseasewas 0% with a mean survival time of 13.5 months (P = 0.014). CONCLUSIONS: The results of the present study suggest that intraoperative radiation therapy with or without external beam radiation therapy was safe and beneficial for patients who underwent curative resection with negative margins and allows the possibility of long-term survival.

Surgical strategy for T2 and T3 gallbladder cancer: is extrahepatic bile duct resection always necessary?

PURPOSE: Resection of the extrahepatic bile duct is not performed uniformly in gallbladder cancer. The study investigated the clinical significance of resection of extrahepatic bile duct (EHBD) in T2 and T3 gallbladder cancer. METHODS: Between 2000 and 2010, 71 T2 or T3 gallbladder cancer patients who underwent R0 resection at Korea University Medical Center were included. Clinicopathological data were reviewed retrospectively. Survival analysis and comparison between EHBD resection and non-resection groups were performed. RESULTS: The 32 men and 39 women had 49 T2 tumors and 22 T3 tumors. The overall survival rate was 67.8 % at 3 years and 47.2 % at 5 years. In multivariate analysis for overall survival, lymphovascular invasion and lymph node metastasis were significant independent predictors. Comparing the patients according to EHBD resection, the EHBD resection group demonstrated significantly longer hospital stay, longer operative time, more transfusion requirement, more extensive liver resection, and less treatment of neoadjuvant therapy. Significantly higher proportions of perineural invasion and lymph node metastasis were noted in the EHBD resection group. There were no statistically significant differences in survival between the EHBD resection and non-resection groups. CONCLUSIONS: Resection of extrahepatic bile duct was not always necessary in T2 and T3 cancers. However, the patients who undergo resection of extrahepatic bile duct tended to have more aggressive tumor characteristics and undergo more aggressive surgical approach. To enhance overall survival for the patients with T2 and T3 gallbladder cancers, surgeons should try to perform R0 resection including EHBD resection.

Metastatic hepatocellular carcinoma to the parotid gland: Case report and review of the literature.

INTRODUCTION: Hepatocellular carcinoma, the most frequent primary hepatic tumor, metastasizes in more than 50% of cases. However, parotid gland metastatic HCCs are very uncommon. We report a patient in whom the finding of a left parotid mass revealed metastatic HCC. PRESENTATION OF CASE: A thirty-six-year-old male presented with a round palpable left neck mass that persisted for 3 months. He had received right hemihepatectomy for hepatocellular carcinoma (HCC). Preoperative evaluation revealed a benign tumor of the parotid gland. We performed superficial parotidectomy. Metastatic hepatocellular carcinoma of the parotid gland was diagnosed. DISCUSSION: Although HCC metastases to the oral cavity have been reported, to date, only 4 cases HCC metastasis to the parotid gland have been reported. Although clinicians and cytopathologists alike both agree that salivary gland fine needle aspiration biopies (FNABs) are highly useful and safe diagnostic alternatives to biopsies and resections, we believe that in specific clinical situations, awareness of potential diagnostic pitfalls in salivary gland FNAB is a necessary part of the microscopic interpretations of these lesions. CONCLUSION: Although rare, since HCC can metastasize to the parotid gland, high suspicion should be maintained in a patient presenting with a parotid mass with a history of HCC. In addition, since potential diagnostic pitfalls in salivary gland fine-needle aspiration (FNA) biopsies exist, incisional or excisional biopsy may be necessary for definite diagnosis of metastatic HCC to the parotid gland.

Primary hepatic marginal zone B cell lymphoma : a case report and review of the literature.

BACKGROUND: Primary hepatic lymphoma (PHL) is a very rare malignancy, and constitutes about 0.016 % of all cases of non-Hodgkin's lymphoma and is often misdiagnosed. The optimal therapy is still unclear and the outcomes are uncertain. Among PHLs, a primary hepatic low-grade marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is extremely rare. METHODS: We present a case of primary hepatic lymphoma (MALT lymphoma) treated with surgical resection and adjuvant chemotherapy. A 38-year-old Korean man, who was diagnosed with chronic hepatitis B 20 years ago, was admitted for liver biopsy after liver lesions were detected on follow-up computed tomography scan (CT). Liver biopsy revealed the diagnosis of marginal zone B-cell malignant lymphoma (MALT lymphoma). The preoperative clinical staging was IE, given that no additional foci of lymphoma were found anywhere else in the body. The patient underwent left hemihepatectomy. Subsequently, the patient received two cycles of CHOP (cyclophosphamide, adriamycin, vincristine, and prednisone) regimen. RESULTS: After 15 months of follow-up, the patient is alive and well without any evidence of disease recurrence. CONCLUSION: Although the prognosis is variable, good response to early surgery combined with postoperative chemotherapy can be achieved in strictly selected patients.

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

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.

Surgical stress response and clinical outcomes of single port laparoscopic cholecystectomy: prospective nonrandomized study.

The levels of interleukin-6 (IL-6) are proportionate to injury; it is the most commonly used quantitative marker in surgical studies. Cytokines and the acute-phase response play an important role in controlling the human immune system. The objective of this study was to compare the systemic acute cytokine response and clinical outcomes of conventional laparoscopic and single port laparoscopic cholecystectomy. We compared patients who underwent single port laparoscopic cholecystectomy (the single port group) with patients who underwent conventional laparoscopic cholecystectomy (the conventional group) according to the clinical variables, IL-6, leukocyte subpopulations, and visual analog scale (VAS) pain score. The mean age in the single port group was significantly younger (P = 0.010) and the mean operation time in the conventional group was significantly shorter (P = 0.002). Postoperative 4-hour VAS pain score was slightly worse in the single port laparoscopic cholecystectomy group, but was not significantly different. We found no difference in clinical outcomes, the level of serum IL-6, C-reactive protein, leukocyte subpopulations, and complications between the two groups. Stress response in single port laparoscopic cholecystectomy is equal to conventional surgery. Postoperative 4-hour VAS pain score was slightly worse and the operation time is significantly longer in the single port laparoscopic cholecystectomy group.

Characterization of hepatocellular carcinoma cell lines based on cell adhesion molecules.

Many studies which focus on the molecules and mechanisms related to the characteristics of the cancer have been performed. In particular, cell adhesion molecules (CAMs) are known to play a central role in the adhesion of cancer cells to vascular endothelial cells. In this study, the expression of CAMs in hepatocellular carcinoma (HCC) cell lines was analyzed and correlated with the characteristics of various HCC cell lines. Eight human HCC cell lines were used in this study. We analyzed the expression of ICAM-1, E-selectin and the integrin subunits of HCC cell lines by western blot analysis and ELISA kit. We estimated the expression of integrin-α5 using western blot analysis and RT-PCR to compare the expression at the gene level with the protein level. In addition, we determined the expression of TGF-ß1, as one of the markers for the cellular activity compared to the levels of expression with the expression of integrin-α3 and -α5. ICAM-1 was highly expressed in all of the cell lines except SNU398 and Hep3B, which exhibit a more aggressive nature among the studied HCC cell lines. E-selectin and integrin subunits varied in all HCC cell lines. In particular, integrin-ß2 was highly expressed on all HCC cell lines. In conclusion, the levels of expression of the CAMs may not affect cellular activity, morphology or tumorigenicity. However, most HCC cell lines show various expressions of CAMs, suggesting that HCC cell lines expressing the major CAMs remain candidates for molecular targeted therapy, which may need to be patient-tailored for therapy according to the molecular profile.

Efficacy of the omental roll-up technique in pancreaticojejunostomy as a strategy to prevent pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Most morbidity and mortality are caused by a pancreatic fistula after pancreaticoduodenectomy (PD), and its prevention is the major concern. We applied the omental roll-up technique around pancreaticojejunostomy and investigated the effectiveness of this technique to prevent a pancreatic fistula. DESIGN: Retrospective study. SETTING: Tertiary hepatobiliary and pancreas surgery clinic, Korea University Guro Hospital, Seoul. PATIENTS: Between March 1, 2009, and March 31, 2011, 68 patients underwent PD. The patients were divided into 2 groups according to the surgical application of the omental roll-up technique around the PJ site: group 1 (those who did not undergo the omental roll-up technique) compared with group 2 (those who did undergo the omental roll-up technique). MAIN OUTCOME MEASURE: The occurrence of a pancreatic fistula. RESULTS: No differences were noted in the clinical characteristics, including patients' demographics and operation-related factors, between the 2 groups. A pancreatic fistula occurred in 23 of 39 patients in group 1 (59%) and in 6 of 29 patients in group 2 (20.7%). Group 2 had a significantly lower incidence of pancreatic fistula (P = .002), and these fistulas were classified as being grade A using the International Study Group on Pancreatic Fistula Definition showing a transient high amylase level in the drainage fluid without significantly affecting the patient's recovery. Drain removal was performed earlier in group 2 (P < .001). Mean postoperative hospital stay was 23.4 days in group 1 compared with 15.9 days in group 2 (P = .009). Overall mortality was 1.5%; however, no deaths were related to a pancreatic fistula. CONCLUSIONS: The omental roll-up technique for the PJ site definitely reduced the occurrence of a pancreatic fistula. Therefore, the omental roll-up technique is a simple and effective strategy to prevent a pancreatic fistula.

Fourteen year surgical experience of gallbladder cancer: validity of curative resection affecting survival.

BACKGROUND/AIMS: Early diagnosis and R0 resection of gallbladder cancer offer a chance for cure. The aims of this retrospective study were to determine the clinicopathologic prognostic factors affecting survival and recurrence. METHODOLOGY: Between 1995 and 2008, a total of 69 patients with gallbladder cancer who underwent surgical exploration or resection were reviewed retrospectively. RESULTS: Of the 69 patients, 34 achieved R0 resection (49.3%). The overall survival rates were 36.6% at 3 years and 24.4 % at 5 years. Multivariate analysis for overall survival demonstrated that non-R0 resection, lymph node dissection, infiltrative tumors, moderate to poor differentiation and depth of invasion were significant independent predictors of poor prognosis. Recurrence occurred in 21 patients. The seventh edition of American Joint Committee on Cancer staging system provided relatively better prediction of survival in patients with gallbladder cancer. CONCLUSIONS: R0 resection and lymph node dissection is an important surgical strategy to improve overall survival. Infiltrative tumor was an independent prognostic factor for disease free survival.

Comparison of hepatocellular carcinoma in American and Asian patients by tissue array analysis.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide. Although some epidemiologic and etiologic differences between Asian and Western HCC are known, detailed comparative studies with pathologic correlations have not been performed. METHODS: Paraffin sections of resected HCC specimens from Memorial Sloan-Kettering Cancer Center and Korea University Medical Center were used to construct tissue microarrays. Immunohistochemical staining of microarray sections was performed using antibodies against markers of proliferation and regulators of cell cycle. Patient data were correlated with staining results. RESULTS: When comparing both cohorts, significant differences were found in expression of p53 and MDM2. In the Asian group, more frequent positive staining for p53 (24%) was observed compared with the American group (9%; P = 0.037). For MDM2, 26% of American cases stained positive compared with 2% of Asian cases (P = 0.0003). No significant differences were found in expression of Ki67, p21, p27, cyclin D1, or bcl2. Female gender, vascular invasion, and lack of viral hepatitis infection correlated with positive MDM2 staining. CONCLUSION: These data likely correlate with differences in molecular pathogenesis of HCC based on racial and regional differences. These findings may have implications in choice of molecular targeted therapies based on patient ethnicity.