Abstract Purpose This study compared the incidence of biliary complication (BC) in adult living donor liver transplant recipients who underwent right-lobe duct-to-duct anastomosis (DDA) with or ...without external biliary drainage (EBD) and intended to optimize EBD tube clamping. Methods This study consisted of a retrospective assessment of EBD effect and a prospective trial for EBD tube-clamping optimization. The retrospective study included the EBD group ( n = 208) and the non-EBD group ( n = 145). The prospective study included 60 patients with EBD. Results In the retrospective study, single DDA was performed in 83.7% of the EBD group and 80.7% of the non-EBD group ( P = .47). One-year overall incidence of BC was 14.4% in the EBD group and 16.8% in the non-EBD group ( P = .48). The incidence of early anastomotic bile leakage was 1.0% in the EBD group and 4.8% in the non-EBD group ( P = .036). In the prospective study, there was no difference in tube-clamping success rates between low- and high-output EBD groups. There was also no statistical difference between the success and failure groups in terms of graft duct size, liver function tests, and post-transplant days at tube clamping. Conclusions The size of our EBD tube was too small for the graft duct size, therefore its main role appeared to be early biliary decompression, which helped prevent bile leakage and also simplified the route of cholangiogram in detecting early BC. Hence, EBD is worthy of performing in selected patients with a high risk of anastomotic bile leak.
ABSTRACTA systematic review of studies completed in the last 11 years for the treatment of acute epididymitis identified 1534 records, of which 29 were assessed for eligibility, and only 1 study met ...the criteria for inclusion. This highlights the need for more prospective studies evaluating treatment regimens for acute epididymitis.
Abstract Background Anomalous portal vein (PV) branching in living donor livers is not uncommon and usually leads to double PV orifices of the right lobe grafts. We have assessed the long-term ...outcomes of portal Y-graft interposition for adult living donor liver transplantation (LDLT). Methods We retrospectively assessed the outcomes of 79 right-lobe LDLTs using portal Y-graft interposition among the 2001 adult LDLTs performed at our institution from January 2002 to December 2010. Results Donor PV types were type III except for one case of type II. Sources of Y-grafts were recipient autologous PV in 76 LDLTs, fresh iliac vein allografts in two, and patch plasty using recipient greater saphenous vein in one. Detailed procedures included a portal Y-graft resection with Y-limbs, corner stay sutures, tying of suture materials under direct mechanical dilatation, and direct edge-to-edge anastomosis to the recipient remnant main PV. Early PV stenting was necessary in five patients (6.3%) due to stenosis or buckling deformity. During a mean follow-up of 42 months, all PVs remained patent until patient death or censoring. Overall 1-, 3-, and 5-year patient survival rates were 93.6%, 88.3%, and 85.5%, respectively. None of the 79 donors experienced major complications requiring reoperation or therapeutic intervention. Conclusions Due to their technical feasibility and excellent long-term outcome, portal Y-graft interposition should be considered a standard procedure for reconstruction of right-lobe grafts with double PV orifices.
Abstract Background De novo malignancy is not uncommon after liver transplantation (LT). Gastric cancer is one of the most common malignancies in both the Korean general population and LT recipients, ...and colorectal cancer prevalence is gradually increasing. Methods Among 3690 adult recipients who underwent LT from January 1999 and December 2013, the screening patterns and prognosis of 26 cases of gastric cancer and 22 cases of colorectal cancer were analyzed. Results For gastric cancer, the mean patient age was 54.6 ± 6.2 years at LT and 59.5 ± 6.7 years at cancer diagnosis, with a post-transplant interval of 60.2 ± 29.8 months. Patients were divided into regular (n = 18) and non-regular (n = 8) screening groups, with early cancer found in 14 and 0 patients; their 2-year survival rates after cancer diagnosis were 93.1% and 33.3% ( P = .006), respectively. Endoscopic resection was successfully performed in 8 patients, all in the regular screening group. For colorectal cancer, the mean patient age was 53.3 ± 6.1 years at LT and 58.1 ± 6.7 years at cancer diagnosis, with a post-transplant interval of 54.3 ± 38.0 months. Patients were divided into regular (n = 19) and non-regular (n = 3) screening groups, with early cancer found in 12 and 0 patients; their 2-year survival rates after cancer diagnosis of 92.3% and 33.3% ( P = .003), respectively. Endoscopic resection was successfully performed in 6 patients, all in the regular screening group. Conclusions LT recipients are strongly advised to undergo regular screening studies for various de novo malignancies, especially cancers common in the general population. Regular endoscopic screening contributes to the timely detection of gastric and colorectal cancers, improving post-treatment survival outcomes.
Abstract Purpose The aim of the present study was to examine the clinical course of nonvascular hepatic ischemia following adult living donor liver transplantation (LDLT). Methods This retrospective ...study reviewed the medical records of 1782 patients who underwent LDLT from January 2003 to September 2010. Nine subjects (0.5%) suffered idiopathic hepatic parenchymal infarcts (IHPI) classified according to the morphology and extent of the infarcted area as peripheral or central. Results Increased levels of liver enzymes were observed in all IHPI patients. Liver cell damage closely correlated with the extent of the infarcted area. Most patients with peripheral-type IHPI showed favoarable spontaneous recovery, occasionally requiring liver support with plasmapheresis or a prolonged period. By contrast, 2 patients with central-type IHPI died due to progressive expansion of the infarcted area with subsequent graft failure. Conclusions In the present study the incidence of IHPI following LDLT was 0.5%. The severity of the infarct depended upon its location and size; central-type IHPI showed a worse prognosis. Thus, special attention should be paid to patients showing a central-type infarction.
Purpose
To analyze the expression of c-Met, and to investigate correlations between the expression of c-Met, clinicopathologic variables, and survival in patients undergoing curative surgery followed ...by adjuvant chemoradiotherapy for extrahepatic bile duct (EHBD) cancer.
Methods
Ninety EHBD cancer patients who underwent curative resection followed by adjuvant chemoradiotherapy were enrolled. Expression of c-Met was assessed with immunohistochemical staining on tissue microarray. The correlation between clinicopathologic variables and survival outcomes was evaluated using Kaplan–Meier method and Cox proportional hazard model.
Results
On univariate analysis, 66 patients (76.7 %) showed c-Met expression. c-Met expression had a significant impact on 5-year overall survival (OS) (43.0 % in c-Met(+) vs. 25.0 % in c-Met(−),
p
= 0.0324), but not on loco-regional relapse-free survival or distant metastasis-free survival (DMFS). However, on multivariate analysis incorporating tumor location and nodal involvement, survival difference was not maintained (
p
= 0.2940). Tumor location was the only independent prognostic factor predicting OS (
p
= 0.0089). Hilar location tumors, nodal involvement, and poorly differentiated tumors were all identified as independent prognostic factors predicting inferior DMFS (
p
= 0.0030, 0.0013, and 0.0037, respectively).
Conclusions
This study showed that c-Met expression was not associated with survival outcomes in EHBD cancer patients undergoing curative resection followed by adjuvant chemoradiotherapy. Further studies are needed to fully elucidate the prognostic value of c-Met expression in these patients.
Abstract Purpose Deterioration of consciousness is a critical situation for liver transplantation (OLT) recipients. The bispectral (BIS) index based on electroencephalographic parameters, is ...primarily used to monitor the depth of unconsciousness. The present study sought to assess the usefulness of posttransplant BIS index to monitor acute-on-chronic liver failure patients. Methods This 1-year retrospective study of 28 adult patients with acute-on-chronic liver failure was performed from July 2011 to June 2012, using post-transplant BIS monitoring. Results The mean patient age was 51 ± 8 years. Their mean pretransplant Child-Turcotte-Pugh score was 12.3 ± 1.4, and the mean Model for End-stage Liver Disease score, 36.4 ± 5.9. After OLT, the mean initial Glasgow Coma Scale (GCS) score and BIS index were 3.4 ± 1.7 and 43.5 ± 9.1, respectively. After 6 hours the mean GCS and BIS values rose to 8.6 ± 4.0 and 52.4 ± 10.3 and after 12 hours to 9.7 ± 3.4 and 61.3 ± 15.7 respectively. Eye opening in response to a voice occurred at a mean of 8.9 ± 6.7 hours after arrival in the intensive care unit regardless of graft function. The mean GCS and BIS values were 10.6 ± 2.8 and 69.1 ± 13.5, respectively. The endotracheal tube was removed after a median of 140 hours; 9 patients required a tracheostomy. Among them 2 died within the first 3 months after OLT. Conclusions BIS monitoring is a noninvasive, simple, easy-to-interpret method to measure consciousness among patients intubated with an endotracheal tube.
Abstract Purpose Complete necrosis of hepatocellular carcinoma (HCC) lesions has occasionally been found by explant pathology after pretransplant neoadjuvant treatment. This study sought to ...investigate the long-term prognostic effect of loss of tumor viability after HCC treatment in living donor liver transplant (LDLT) recipients. Methods We reviewed retrospectively the 5-year records of 37 patients who demonstrated nonviable HCC on explant pathology. Results The most common primary disease was hepatitis-B-virus-associated liver cirrhosis ( n = 34). Single explant tumors were found in 29 patients; the mean maximal tumor size was 2.1 ± 0.9 cm (range: 0.8–4.0). No patients showed microvascular invasion. The median level of alpha-fetoprotein was 12 ng/mL (range: 1–1160). The 1 patient who showed a recurrence at 20 months remains alive more than 6 years after adrenalectomy and repeated pulmonary metastasectomy. The 5-year HCC recurrence rate was thus 2.1%. There were 2 late mortalities, each due to graft failure and recurrent gastric cancer. The overall patient survival rate was 97.3% at 5 and 92.7% at 10 years. Conclusions The results of this study revealed that the loss of tumor viability induced by pretransplant neoadjuvant treatment definitely decreased the risk of post-transplant HCC recurrence. Therefore, patients with nonviable HCC can be regarded as members of a superselect group with minimal risk for HCC recurrence, and may be exempted from routine HCC screening.
Abstract Background A considerable proportion of recipients of liver transplantations who are presented hepatitis B immunoglobulin (HBIG) monotherapy for hepatitis B virus (HBV) prophylaxis develop ...HBIG resistance. In this study, we investigated the mutation patterns in the major hydrophilic region (MHR) of amino acid sequences 100 to 160. Methods Using the gene sequence analyzer for amino acid sequences 0 to 226 in the S/pre-S region we analyzed blood samples of 15 patients showing HBIG resistance after high-dose HBIG prophylaxis. Results Various mutations in the MHR were observed in 14/15 samples: Gly145Arg mutation in 8/13 Adr subtype and 1/2 Ayw subtype samples (60%). The next most common mutation was Gly165Trp in 8/13 Adr subtype but neither of 2 Ayw subtype samples (53.3%). Concurrent antiviral resistance was noted in 5 patients: lamivudine ( n = 5), or entecavir ( n = 3), but not adefovir, suggesting the occurrence of simultaneous, antiviral cross-resistances. Two patients underwent retransplantation due to the progression of HBV infection despite vigorous antiviral therapy. At diagnosis of HBV recurrence, the mean HBV DNA load was 6.5 × 106 copies/mL; 4 patients showed paradoxical coexistence of anti-HBs and HBsAg. Currently, 2 subjects show low-level HBV DNA replication in peripheral blood, although the other 12 had no DNA replication after prolonged antiviral therapy. Conclusions This study suggested that various mutations in the “a” determinant were associated with HBIG resistance. Since treatment failure to rescue antiviral therapy was often associated with delayed detection of HBV recurrence rather than concurrent antiviral resistance, frequent HBV surveillance using more sensitive screening tests, such as HBeAg and HBV DNA polymerase chain reaction assay, seems to be mandatory.
ABO‐incompatible (ABOi) dual‐graft (DG) adult living donor liver transplantation (ALDLT) is not commonly performed due to its inherently intricate surgical technique and immunological complexity. ...Therefore, data are lacking on the short‐ and long‐term clinical outcomes of ABOi DG ALDLT. We performed a retrospective study by reviewing the medical records of patients who underwent ABOi DG ALDLT between 2008 and 2014. Additionally, computed tomography volumetric analysis was conducted to assess the graft regeneration rate. The mean age of a total of 28 recipients was 50.2 ± 8.5 years, and the mean model for end‐stage liver disease score was 12.2 ± 4.6. The 1‐, 3‐, and 5‐year patient survival rate was 96.4% during the mean follow‐up period of 57.0 ± 22.4 months. The 1‐, 3‐, and 5‐year graft survival rate was 96.4%, 94.2%, and 92.0%, respectively, and no significant differences were observed between ABO‐compatible (ABOc) and ABOi grafts (P = .145). The biliary complication rate showed no significant difference (P = .195) between ABOc and ABOi grafts. Regeneration rates of ABOi grafts were not significantly different from those of ABOc grafts. DG ALDLT with ABOi and ABOc graft combination seems to be a feasible option for expanding the donor pool without additional donor risks.
Dual‐graft adult living donor liver transplantation with ABO‐incompatible grafts demonstrates an acceptable outcome in patient and graft survival, and proves to be safe in regards to biliary complications associated with the ABO incompatibility, which suggests its feasibility to expand the living liver donor pool without increasing donor risks.
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