Randomized controlled study of the effect of octreotide on pancreatic exocrine secretion and pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Octreotide is known to decrease the rate of postoperative complication after pancreatic resection by diminishing exocrine function of the pancreas. The aim of this study was to evaluate the effect of octreotide in decreasing exocrine excretion of pancreas and preventing pancreatic fistula. MATERIALS AND METHODS: Prospective randomized trial was conducted involving 59 patients undergoing pancreaticoduodenectomy for either malignant or benign tumor, 29 patients were randomized to receive octreotide; 30 patients allotted to placebo. All pancreaticojejunal anastomosis was performed with external stent of negative-pressured drainage and the amount of pancreatic juice through the external stent was measured until postoperative 7th day. Pancreatic fistula was recorded. RESULTS: There were no differences in demographics, pancreatic texture and pancreatic duct diameter between the octreotide and placebo group. The median output of pancreatic juice was not significantly different between both groups during 7 days after surgery. When the patients were stratified according to the diameter of pancreatic duct (duct ≤5 mm, > 5 mm), there were no significant differences in daily amount of pancreatic juice, however, when stratified according to pancreatic texture, median output of pancreatic juice was significantly lower in patients with hard pancreas compared with those with soft pancreas from 5 day to 7 day after surgery (p < 0.05). No significant differences in pancreatic fistula and postoperative complications were found between the octreotide and placebo groups. CONCLUSIONS: Prophylactic octreotide is not effective to inhibit the exocrine secretion of the remnant pancreas and does not decrease the incidence of pancreatic fistula after pancreaticoduodenectomy.

Prognostic factors after curative resection hepatocellular carcinoma and the surgeon's role.

PURPOSE: Patient, surgical, and tumor factors affect the outcome after surgical resection for hepatocellular carcinoma (HCC). The surgical factors are only modifiable by the surgeon. We reviewed our experience with curative resection for HCC in terms of surgical factors. METHODS: After analyses of the prospectively collected clinical data of 256 consecutive patients undergoing surgical resection for HCC, prognostic factors for disease-free survival (DFS) and overall survival (OS) were identified; all patients were stratified by tumor diameters > or <5 cm and their outcomes were compared. RESULTS: Multivariate analyses showed that microvascular invasion, estimated blood loss, blood transfusion, and the number of tumors were independent adverse prognostic factors for DFS, whereas microvascular invasion, serum alpha fetoprotein, and tumor diameter were independent adverse prognostic factors for OS. Blood transfusion had borderline significance (P = 0.076). After stratification by tumor diameter, blood transfusion was only associated with poor DFS and OS in patients with tumor diameters > 5 cm. CONCLUSION: Tumor recurrence after liver resection for HCC depends on tumor status, bleeding, and transfusions, which subsequently lead to poor patient survival. Surgeons can help improve the prognosis of patients by minimizing blood loss and transfusion, particularly in patients with larger tumors.

Does the Gadoxetic Acid-Enhanced Liver MRI Impact on the Treatment of Patients with Colorectal Cancer? Comparison Study with ¹8F-FDG PET/CT.

OBJECTIVES: We evaluated the value of Gadoxetic acid-enhanced liver MRI in the preoperative staging of colorectal cancer and estimated the clinical impact of liver MRI in the management plan of liver metastasis. METHODS: We identified 108 patients who underwent PET/CT and liver MRI as preoperative evaluation of colorectal cancer, between January 2011 and December 2013. We evaluated the per nodule sensitivity of PET/CT and liver MRI for liver metastasis. Management plan changes were estimated for patients with metastatic nodules newly detected on liver MRI, to assess the clinical impact. RESULTS: We enrolled 131 metastatic nodules (mean size 1.6 cm) in 41 patients (mean age 65 years). The per nodule sensitivities of PET/CT and liver MRI were both 100% for nodules measuring 2 cm or larger but were significantly different for nodules measuring less than 2 cm (59.8% and 95.1%, resp., P = 0.0001). At least one more metastatic nodule was detected on MRI in 16 patients. Among these, 7 patients indicated changes of management plan after performing MRI. CONCLUSIONS: Gadoxetic acid-enhanced liver MRI detected more metastatic nodules compared with PET/CT, especially for small (<2 cm) nodules. The newly detected nodules induced management plan change in 43.8% (7/16) of patients.

ERCC1 Can Be a Prognostic Factor in Hilar Cholangiocarcinoma and Extrahepatic Bile Duct Cancer, But Not in Intrahepatic Cholangiocarcinoma.

PURPOSE: There are three types of bile duct cancer, intrahepatic cholangiocarcinoma (ICC), hilar cholangiocarcinoma (HC), and extrahepatic cholangiocarcinoma (EHC). Despite different clinical presentation, the same protocol has been used in treatment of patients with these cancers. We analyzed clinicopathologic findings and protein expression in order to investigate the difference and the specific prognostic factors among these three types of cancers. MATERIALS AND METHODS: We conducted a retrospective review of 104 patients diagnosed with bile duct cancer at Seoul St. Mary's Hospital between January 1994 and May 2004. We performed immunohistochemical staining for p53, cyclin D1, thymidine phosphorylase, survivin, and excision repair cross-complementing group 1 (ERCC1). RESULTS: Of the 104 patients, EHC was most common (44.2%). In pathologic findings, perineural invasion was significantly less common in ICC. Overall survival was similar among the three types of cancer. Lymph node invasion, lymphatic, and venous invasion showed a significant association with survival outcome in ICC, however, the differentiation of histologic grade had prognostic significance in HC and EHC. No difference in protein expression was observed among these types of cancer, however, ERCC1 showed a significant association with survival outcome in HC and EHC, not in ICC. CONCLUSION: Based on our data, ICC showed different characteristics and prognostic factors, separate from the other two types of bile duct cancer. Conduct of further studies with a large sample size is required in order to confirm these data.

Clinical analysis of emergency liver transplantation: the role of living donor liver transplantation.

The current liver allocation system requires reevaluation because of the advancements in peri-transplantation care and surgical techniques. And, the role of living donor liver transplantation (LDLT) in an emergency has not been determined yet. Retrospective review of all patients undergoing emergency liver transplantation (LT) from January 2000 to June 2010 was conducted, and clinical data were analyzed. Of the total 505 LTs, 69 patients (13.7%) underwent an emergency LT. Of these, 54 patients (78.3%) underwent LDLT using a right liver, and 15 patients (21.7%) underwent deceased donor liver transplantation (DDLT). The overall hospital mortality was 21.7% (15/69). The leading cause of death after transplantation was sepsis (60.0%). Multivariate analysis demonstrated that a model for end-stage liver disease (MELD)>33 [hazard ratio (HR), 16.6; 95% confidence interval (CI), 1.443-191.632; p=0.024] and existence of pre-transplantation intubation (HR, 18.2; 95% CI, 1.463-225.483; p=0.024) were independent factors associated with poor survival after emergency LT. LDLT group and DDLT group showed no difference in hospital mortality (p=0.854) and graft survival (p=0.861). Thus, MELD score and respiratory insufficiency could be parameters predicting post-transplant survival. And, LDLT using the right liver could be an appropriate alternative to DDLT in an emergency.

Surgical outcome of right liver donors in living donor liver transplantation: single-center experience with 500 cases.

BACKGROUND: With the increasing number of living donor liver transplantation (LDLT), concerns regarding morbidity and mortality of donors have become inevitable. Thus, the aim of the present study was to find ways to reduce the rate of morbidity and mortality of donors by analyzing our experience. METHODS: A retrospective clinicopathologic analysis was performed for 500 consecutive living donors who underwent donor right hepatectomy between May 1999 and February 2011. We chronologically divided those procedures into three periods: period A (n = 100), period B (n = 200), and period C (n = 200). Surgical outcomes according to each period were then compared. RESULTS: Over time, the following factors have decreased: the operative time, the amount of transfusions during surgery, hospital stay, and the incidence of biliary complications. No mortality developed. Even though the total complication rate was high (21.6 %, n = 108) including 10.6 % (n = 53) of biliary complications, the grade 3 complication rate was only 9.4 % (n = 47). In most patients with grade 3 complication, interventional therapies via radiologic or endoscopic approaches corrected these complications, and reoperation was required for ten patients (2 %). Whereas biliary complications were related with operation period (period B or C compared to period A; relative risk [RR] 2.10, P = 0.049, 95 % CI 1.01-4.39) and operative time (RR 1.01, P = 0.027, 95 % CI 1.00-1.02), postoperative hyperbilirubinemia (serum total bilirubin ≥ 5 mg/dL) was related with male gender (RR 2.68, P = 0.039, 95 % CI 1.05-6.85) and ≥ 25 % liver steatosis (RR 3.35, P = 0.053, 95 % CI 0.99-11.38). CONCLUSIONS: Optimization of donor selection as well as institutional experience is imperative to improve the surgical outcome. Even though donor hepatectomy was associated with relatively higher complication rate, most complications showed low-grade severity which could be corrected by interventional therapies.

Hepatic artery reconstruction and successful management of its complications in living donor liver transplantation using a right lobe.

BACKGROUND: The aim of the present study was to improve the techniques of hepatic artery (HA) reconstruction and to properly manage arterial complications after living donor liver transplantation (LDLT). METHODS: Prospectively collected data collected from 371 patients who underwent adult LDLT using a right lobe from January 2000 to August 2009 were retrospectively reviewed. RESULTS: Of 17 patients (4.6%, 17/371) with double HA stumps in the graft, 12 patients (70.6%) received dual HA reconstruction. HA complications were composed of thrombosis (n = 6), pseudoaneurysm (n = 2), and stenosis (n = 4), showing 3.2% (12/371) of incidence. In patients with HA thrombosis, whereas operative thrombectomies with re-anastomosis rescued all the grafts in early attack (n = 3, ≤1 wk), angiographic thrombolysis successfully reestablished the flow in patients with late attack (n = 3, >1 wk). In all patients with HA complications, except for one, all of our treatment modalities - operation and angiographic intervention - resulted in successful rescue of grafts and no patient received re-transplantation because of HA complications. CONCLUSION: Prompt diagnosis of HA complications by serial post-operative Doppler ultrasound and corresponding treatment strategies, including operative and radiological intervention, can rescue both grafts and patients without necessitating re-transplantation.

Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis.

The aim of this study was to improve outcomes in living donor liver transplantation (LDLT) patients with portal vein thrombosis (PVT). Of 246 adult patients who underwent LDLT with a right lobe graft between January 2000 and May 2007, PVT was diagnosed in 50 patients (20.3%), who were further subdivided into partial (n = 39, 78%) and complete (n = 11, 22%) types. Patients with PVT, especially complete PVT, showed high incidences of variceal bleeding (p = 0.021), operative RBC transfusion (p < 0.046) and a post-transplantation complications related to bleeding (p = 0.058). We also classified PVT according to its location and the presence of collaterals: type I (n = 41, 82%): PVT localized above the confluence of the splenic and superior mesenteric veins (SMV); type II (n = 7, 14%): PVT extending below the confluence with a patent distal SMV; type III (n = 2, 4%): complete portal vein and SMV thrombosis except for a coronary vein. LDLT could be safely undertaken in patients with PVT without increased mortality. In our type II and III PVT, when thrombectomy fails, jump grafting using a cryopreserved vessel may serve as a reliable alternative method to restore portal flow.