Abstract Purpose Combined hepatocellular carcinoma (HCC) and cholangiocellular carcinoma (CCC) is a rare pair of intrahepatic malignancies. Differential diagnosis among combined HCC-CCC, HCC, or CCC ...can be difficult; thus malignancies other than ordinary HCC are occasionally encountered unexpectedly in explanted liver specimens. The present study analyzed the long-term outcomes of liver transplantation (OLT) among patients with HCC-CCC. Methods Between January 1999 and December 2009, we performed 2137 adult OLT at our institution including 15 cases of pathologically confirmed HCC-CCC, who all underwent OLT with a pretransplant diagnosis of HCC. We reviewed retrospectively the medical records of these 15 patients. Results Their mean age was 58.9 ± 7.2 years. The median preoperative alpha-fetoprotein level was 32.6 ng/mL. Fourteen patients underwent living donor and one deceased donor OLT. The Milan criteria were met in 12 cases. A single tumor was identified in 8 and multiple lesions in 7 patients. The maximal tumor diameter was 2.9 ± 1.7 cm. Seven patients experienced tumor recurrences: including 6 within the first 12 months. All of the patients who experienced recurrences died at a median 4 months after that diagnosis. The overall patient survival rates were 66.7% at 1 year and 60.0% at 3 and 5 years. Disease-free patient survival rates were 60.0% at 1 year and 53.3% at 3 and 5 years. Conclusions Patients with combined HCC-CCC showed a high rate of early recurrences, particularly within the first year.
Abstract Background Adult liver transplantation (OLT) recipients occasionally show serious acute cardiopulmonary dysfunction, requiring intensive care. We assessed the role of extracorporeal membrane ...oxygenation (ECMO) support in adult recipients facing acute pulmonary failure and refractory to conventional mechanical ventilation and concurrent nitric oxide gas inhalation. Methods From January 2008 to March 2011, 18 adult OLT recipients at our institution required ECMO support: 12 due to pneumonia and 6 to adult respiratory distress syndrome. Their mean age was 55.7 ± 6.9 years and mean Model for End-stage Liver Disease score, 24.8 ± 8.5. Twelve patients had undergone living donor and six deceased donor OLT. Results A venovenous access mode and concurrent continuous venovenous hemodiafiltration were used in all patients. There were no procedure-related complications. Eight patients (44.4%) were successfully weaned from ECMO upon the first attempt after a mean support of 11.9 ± 6.1 days, but the other 10 died due to overwhelming infection. Univariate analysis revealed no significant pre-ECMO risk factor for treatment failure but C-reactive protein concentration at the time of ECMO differed significantly among patients who did versus did not survive after ECMO. Conclusions ECMO as rescue therapy may be a final therapeutic option for OLT recipients with refractory pulmonary dysfunction who would otherwise die due to hypoxemia from severe pneumonia or adult respiratory distress syndrome.
Abstract Purpose De novo malignancy is not uncommon after liver transplantation (OLT). We have compared the incidence of novo malignancy following OLT with those among the general Korean population. ...Methods Between January 1998 and December 2008, 1952 adult OLT were performed, including 1714 living donor and 238 deceased donor grafts whose medical records were retrospectively reviewed. Results Among the 1952 patients, 44 (2.3%) showed de novo malignancies after a mean posttransplant period of 41 months. Among the 14 types of malignancy the most frequent was stomach cancer ( n = 11; 25.0%), colorectal cancer ( n = 9; 20.5%), breast cancer ( n = 4; 9.1%), and thyroid cancer ( n = 3; 6.8%). These patients underwent aggressive treatment, including surgery, chemotherapy, and radiotherapy, except for one patient with an aggressive primary liver cancer. Over a mean follow-up of 45 months after diagnosis of de novo malignancy, 13 patients (29.5%) died; the overall 3-year patient survival rate was 67.5%. The relative risk of malignancy following OLT was 7.7-fold higher in men and 7.3-fold higher in women than the Korean general population. Conclusions OLT recipients must be checked periodically for de novo malignancy throughout their lives, especially for cancers common in the general population.
Abstract Purpose Pneumocystis carinii pneumonia (PCP) is an opportunistic infection associated with morbidity and mortality in solid-organ transplant recipients. We retrospectively assessed the ...characteristics and outcomes of liver transplant (OLT) recipients with PCP compared with those of patients with severe non- P carinii pneumonia (non-PCP) who required intensive care with mechanical ventilation. Methods During the 2-year period between January 2008 and December 2009, 43 adult OLT recipients had severe pneumonia requiring mechanical ventilation; of these, 8 (19%) had PCP. During this period, routine antibiotic prophylaxis was administered for the first 6 months after OLT. Results The median period from OLT to development of PCP was 9.5 months (range, 1–67); the 1-year incidence was 0.9%. The 6 and 6 to 12-month incidences of non-PCP were 4.2% and 0.3%, respectively, and those of PCP were 0.3% and 0.6%, respectively. Four of 8 patients (50%) in the PCP group had a recent history of a rejection episode. PCP was associated with a higher incidence of prior antirejection treatment. There were no significant differences between PCP and non-PCP groups in age, gender, preoperative Model for End-stage Liver Disease score, primary diagnosis, graft type, and total number of rejection episodes. Conclusions These results indicate that the risk of PCP in OLT recipients is closely related to strong immunosuppressive treatment for acute cellular rejection episodes, suggesting the importance of PCP prophylaxis in these patients. Because most patients developed PCP at around 1 year, it may be advisable to prolong routine post-OLT PCP prophylaxis for 12 months, especially among patients receiving antirejection treatment.
This study investigated the diagnosis of renal diseases using a biochip capable of detecting nano-sized biomarkers. Raman measurements from a kidney injury model were taken, and the feasibility of ...early diagnosis was assessed.
Rat models with mild and severe unilateral ureteral obstructions were created, with the injury to the kidney varying according to the tightness of the stricture. After generating the animal ureteral obstruction models, urine was collected from the kidney and bladder.
After confirming the presence of renal injury, urine drops were placed onto a Raman chip whose surface had been enhanced with Au-ZnO nanorods, allowing nano-sized biomarkers that diffused into the nanogaps to be selectively amplified. The Raman signals varied according to the severity of the renal damage, and these differences were statistically confirmed.
These results confirm that ureteral stricture causes kidney injury and that signals in the urine from the release of nano-biomarkers can be monitored using surface-enhanced Raman spectroscopy.
Abstract Purpose Patients with advanced liver diseases are at increased risk of cardiovascular events, resulting in a higher incidence of cardiac complications following liver transplantation (OLT). ...We assessed the clinical value of computed tomographic coronary arteriography (CTCAG) as a routine preoperative cardiac evaluation test in adult patients scheduled for living donor OLT (LDLT). Methods This single-center, prospective, observational study evaluated 247 adult patients being assessed for LDLT from April 2010 to March 2011. CTCAG was performed in patients with all-negative findings on routine cardiac workup, including thallium single photon emission computed tomography (SPECT). Results Of the 247 patients evaluated, 27 (10.9%) showed abnormal findings on CTCAG, with 18 (7.3%) showing mild to moderate involvement of one vessel; 7 (2.8%), two-vessel; and 2 (0.8%), three-vessel involvement. Coronary artery calcification was identified in patients with significant coronary artery stenosis. No adverse events occurred after CTCAG. Noticeable hypotensive episodes during LDLT surgery occurred in 5% of patients, mostly related to massive bleeding or postperfusion syndrome. During the first 3 months after LDLT, 3% of patients showed stress cardiomyopathy, but all recovered with supportive care. Conclusions The poor general medical condition of LDLT candidates and the diagnostic accuracy of CTCAG suggest that this test should be included in the routine pretransplant cardiac workup, along with thallium SPECT, for these patients.
Abstract Objective The cosmetic aspects of abdominal skin incisions are a matter of concern for both live liver donors and surgeons. We performed a prospective comparative study on the use of ...minilaparotomy to perform right liver graft harvests with and without hand-assisted laparoscopic surgery (HALS). Methods Young donors were indicated for surgery using minilaparotomy with or without HALS. In the non-HALS group (n = 20), a 10–12-cm-long right subcostal incision was used for right liver graft harvest. In the HALS group (n = 20), an 8-cm-sized right subcostal incision was used for hand assistance and 3 laparoscopic holes made for manipulation. The retrohepatic inferior vena cava (IVC) was initially laparoscopically dissected while using air inflation. The skin incision was extended to 10–12 cm, and then hilar dissection and hepatic transection were performed through the skin incision. Results In all 40 donors in the study cohort, safe uneventful harvesting of the right liver grafts was successfully achieved through the minilaparotomy incisions. The HALS group required an additional 30 minutes for laparoscopic preparation and dissection compared with the non-HALS group. HALS facilitated retrohepatic IVC dissection, and the remaining part of the surgery was the same as that for minimal-incision surgery. The minimal skin incision for the delivery of the liver from the abdomen was an average 10 cm for grafts <500 g and 12 cm for grafts ≥700 g. Compared with the patient profiles, there were no differences regarding donor age, body mass index, graft weight, intraoperative blood loss, postoperative increase in peak liver enzymes, total hospital stay, and incidence of postoperative complications. Conclusions HALS facilitates the performance of donor hepatectomy with the use of a minimal incision, which probably allows for a wider selection of living donors.
Abstract Background After > 2000 adult living donor liver transplants (LDLTs), we observed minimization of the complication rate using case-by-case modification of venous outflow reconstruction in ...right liver graft (RLG), standardization seeking intend to provide a hemodynamic- based, regeneration-compliant hepatic outflow reconstruction. Methods We retrospectively examined 100 consecutive adult LDLT using modified RLG before and after application of RLG standardization to compare the 6-month incidences of vascular outflow complications. Result The right hepatic vein stenting rate for first 6 months was 5% in the customized group and 1% in the standardized group ( P = .212). The middle hepatic vein stenting rate for first 6 months was 9% in the customized group and 4% in the standardized group ( P = .373). The inferior right hepatic vein stenting rate for first 6 months was 12.8% in the customized group and 7.1% in the standardized group ( P = .472). The overall 6-month patient survival rate was 94% in the customized group and 95% in the standardized group ( P = .867). The overall incidence of significant RLG venous outflow complications was 19% in the customized group and 8% in the standardized group ( P = .023). Conclusion Standardization as a universal graft model seemed to be more effective and feasible than conventional graft customization requiring individualized case-by-case modification.
Abstract Purpose To assess the incidence and management of postoperative abdominal bleeding after orthotopic liver transplantation (OLT) and to identify risk factors for abdominal bleeding. Methods ...We retrospectively reviewed the medical records of 1039 patients who underwent OLT at our institution from January 2008 to December 2010 seeking to identify subjects with posttransplantation abdominal bleeding, defined as any hemorrhage requiring radiologic intervention or laparotomy within the first month. Results Among the 1039 patients, 94 (9%) showed abdominal bleeding, occurring at a mean of 6.1 days (range, day 1 to 21 days). Active bleeding was controlled by endovascular interventional techniques (n = 37; 39%), by surgical ligation or vascular reconstruction (n = 43; 46%), or by sequential combinations of endovascular intervention and surgery (n = 14; 15%). The most frequent bleeding sites for radiologic intervention were the right inferior phrenic artery (n = 14), right and left epigastric arteries (n = 7), intercostal artery (n = 5) and right renal capsular artery (n = 4). The most frequent bleeding sites requiring laparotomy were the hepatic artery (n = 9), diaphragm (n = 8), inferior vena cava (n = 5), abdominal drain insertion site (n = 4), portal vein anastomosis site (n = 4), abdominal wall (n = 3), liver graft cut surface (n = 3), hilar plate (n = 3), and greater omentum (n = 3). Bleeding episodes were associated with greater patient age and increased intraoperative blood loss. Conclusions The risk of bleeding from coagulopathy and iatrogenic injury is high during the early posttransplantation period. This risk of bleeding can be minimized by meticulous surgical dissection and bleeding control.
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.
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