A Multicenter, Randomized, Open-Label Study to Compare the Efficacy and Safety of Tacrolimus and Corticosteroids in Combination With or Without Mycophenolate Mofetil in Liver Transplantation Recipients Infected With Hepatitis B Virus.

BACKGROUND: Mycophenolate mofetil exhibits pharmacologic mechanisms different from calcineurin inhibitors. Therefore, the dose of calcineurin inhibitors can be reduced along with side effects for effective immunosuppression. We aimed to evaluate the efficacy and safety of tacrolimus and corticosteroid in combination with or without mycophenolate mofetil in living donor liver transplantation (LDLT) recipients infected with hepatitis B virus (HBV). METHODS: A randomized, open-label, comparative, multicenter, phase IV study was conducted with 119 patients from January 2014 to September 2017. In the full analysis set population, 58 and 59 patients were included in the study group (triple-drug regimen: TacroBell + My-rept + corticosteroid) and the control group (dual-drug regimen: TacroBell + corticosteroid), respectively. In the per protocol set population, 49 and 42 patients were included in the study and control groups, respectively. RESULTS: In the full analysis set population, the incidence of biopsy-proven acute cellular rejection (rejection activity index score ≥4) was 3.4% in the study group; however, this finding was not observed in the control group (P = .468). Hepatitis B virus recurrence was observed in one patient in the control group. No cases of biopsy-proven acute cellular rejection and HBV recurrence were observed in the per protocol set population. The incidences of serious adverse events were 25.9% and 18.0% in the study and control groups, respectively; however, the difference between the groups was not statistically significant (P = .376). CONCLUSION: Although the study involved a small number of patients, the triple-drug regimen can be considered safe and effective for immunosuppression after living donor liver transplantation in patients infected with HBV.

Acute cholecystitis: predictive clinico-radiological assessment for conversion of laparoscopic cholecystectomy.

BACKGROUND: Previous studies evaluating predictive factors for the conversion from laparoscopic to open cholecystectomy have reported conflicting conclusions. PURPOSE: To create a risk assessment model to predict the conversion from laparoscopic to open cholecystectomy in patients with acute calculous cholecystitis. MATERIAL AND METHODS: A retrospective review of patients with acute calculous cholecystitis with available preoperative contrast-enhanced computed tomography (CT) findings who underwent laparoscopic cholecystectomy was performed. Forty-four parameters-including demographics, clinical history, laboratory data, and CT findings-were analyzed. RESULTS: Among the included 581 patients, conversion occurred in 113 (19%) cases. Multivariate analysis identified obesity (odd ratio [OR] 2.58, P = 0.04), history of abdominal surgery (OR 1.78, P = 0.03), and prolonged prothrombin time (OR 1.98, P = 0.03) as predictors of conversion. In preoperative CT findings, the absence of gallbladder wall enhancement (OR 3.15, P = 0.03), presence of a gallstone in the gallbladder infundibulum (OR 2.11, P = 0.04), and inflammation of the hepatic pedicle (OR 1.71, P = 0.04) were associated with conversion. Inter-observer agreement for CT study interpretation was very good (range 0.81-1.00). A model was created to calculate the risk for conversion, with an area under the receiver operating characteristic curve of 0.87. The risk for conversion, estimated based on the number of factors identified, was in the range of 5.3% (with one factor) to 86.4% (with six factors). CONCLUSION: Obesity, history of abdominal surgery, prolonged prothrombin time, absence of gallbladder wall enhancement, presence of a gallstone in the gallbladder infundibulum, and inflammation of the hepatic pedicle are associated with conversion of laparoscopic to open cholecystectomy.

Endobiliary radiofrequency ablation for distal extrahepatic cholangiocarcinoma: A clinicopathological study.

BACKGROUND: Most patients with distal extrahepatic cholangiocarcinoma have developed jaundice or cholangitis at the time of initial diagnosis, which can delay surgery. We aim to evaluate the actual EB-RFA ablation volume and validated the clinical feasibility of preoperative endobiliary radiofrequency ablation (EB-RFA) for resectable distal extrahepatic cholangiocarcinoma. METHODS: The medical records of patients who underwent EB-RFA from July 2016 to June 2017 at a single tertiary academic medical center were reviewed. Inclusion criteria were patients with resectable distal extrahepatic cholangiocarcinoma who required preoperative biliary decompression. Clinical outcomes of EB-RFA were reviewed retrospectively and the surgical specimens were reevaluated. RESULTS: Of the eight patients who required a delayed operation, preoperative EB-RFA was successfully performed without serious complications including peritonitis, hemobilia, or perforation. Although curative resection was attempted in all patients, one patient underwent open and closure due to hepatic metastasis. Seven patients underwent curative surgical resection and the histology revealed that median maximal ablation depth was 4.0 mm (range, 1-6) and median effective ablation length (histological ablation length/fluorosocopic ablation length) was 72.0% (range, 42.1-95.3). CONCLUSIONS: EB-RFA partially ablated human cancer tissue and preoperative EB-RFA might be a safe and feasible in patients with distal extrahepatic cholangiocarcinoma who require a delayed operation. Ablation of the target lesion longer than the estimated length by fluoroscopy may improve the efficacy of EB-RFA.

Synchronous Peripancreatic Lymph Node Gastrinoma and Gastric Neuroendocrine Tumor Type 2.

A 34-year-old man was referred to our hospital with gastric polypoid lesions and biopsy-confirmed neuroendocrine tumor (NET). Computed tomography (CT) revealed a 3×3.5×8-cm retroperitoneal mass behind the pancreas, with multiple hepatic metastases. His serum gastrin level was elevated to 1,396 pg/mL. We performed a wedge resection of the stomach, a right hemi-hepatectomy, and a retroperitoneal mass excision. After careful review of the clinical, radiological, histopathological, and immunohistochemical findings, peripancreatic gastrinoma, and synchronous gastric NET were ultimately diagnosed. We reviewed a CT scan that had been performed 6 years previously after surgery for a duodenal perforation. There was no evidence of gastric or hepatic lesions, but the retroperitoneal mass was present at the same site. Had gastrinoma been detected earlier, our patient could have been cured using less invasive treatment. This case demonstrates how important it is to consider Zollinger-Ellison syndrome in patients with a recurrent or aggressive ulcer.

A Case of Superior Mesenteric Artery Aneurysm Mimicking an Abdominal Aortic Aneurysm and Presenting as a Pulsating Abdominal Mass.

A 62-year-old male with a smoking history of 30 pack-years presented with a 1-year history of a periumbilical pulsating mass. He had been treated for hypertension for 2 years. Physical examination revealed a huge pulsating mass in the periumbilical abdomen. Femoral and popliteal arterial pulses were palpable. Computed tomography showed arterial dissection in the proximal segment of the superior mesenteric artery, a huge aneurysm (52×50 mm) with mural thrombus and two smaller aneurysms (20×20 mm) in the right ileocolic and ileal branches, along with atherosclerotic changes. Interposition using the great saphenous vein was performed after aneurysmal isolation and ligation of jejunal branches in the sac. Distal flow was reestablished by end-to-end and end-to-side anastomoses of the right ileocolic and ileal branches, respectively. No complications were observed at 1-year follow-up.

A Surgeon's Perspective of Abdominal Wall Endometriosis at a Caesarean Section Incision: Nine Cases in a Single Institution.

Abdominal wall endometriosis in a Caesarean section scar (AEC) is an infrequent type of extrapelvic endometriosis which rarely transforms into a malignant lesion. A painful mass located in the scar of a Caesarean section is a typical sign of AEC. This condition is diagnosed preoperatively using imaging modalities such as computed tomography and ultrasonography, as well as fine-needle aspiration. Although AEC has typical signs, general surgeons often misdiagnose it due to its rarity. Herein, we report our experience of AEC in a single institution.

Factors influencing hepatocellular carcinoma prognosis after hepatectomy: a single-center experience.

BACKGROUND/AIMS: Recurrence after hepatic resection is one of the most important factors impacting the prognosis and survival of patients with hepatocellular carcinoma (HCC). We identified prognostic factors affecting overall survival (OS) and disease-free survival (DFS) in patients with HCC after hepatic resection. METHODS: This study was of a retrospective cohort design, and 126 patients who underwent hepatic resection for HCC at Gachon University Gil Medical Center between January 2005 and December 2010 were enrolled. Various clinical, laboratory, and pathological data were evaluated to determine the prognostic factors affecting OS and DFS. RESULTS: Two- and 4-year OS and 2- and 4-year DFS were 78.1% and 65% and 51.1% and 26.6%, respectively. In a multivariate analysis, preoperative α-fetoprotein (> 400 ng/mL), tumor size (≥ 5 cm), multiple tumors (two or more nodules), presence of portal vein invasion, modified Union for International Cancer Control (UICC) stage III/IV, and Barcelona Clinic Liver Cancer (BCLC) stage B/C were independent prognostic factors affecting a shorter OS. In the multivariate analysis, presence of microvascular invasion, modified UICC stage III/IV, and BCLC stage B/C were independent prognostic factors for a shorter DFS. CONCLUSIONS: The presence of vascular invasion was an independent poor prognostic factor for OS and DFS in patients with HCC after hepatic resection. Thus, close postoperative surveillance for early detection of recurrence and additional treatments are urgently needed in patients with vascular invasion after hepatic resection.

The prognostic significant of percentage drop in serum CEA post curative resection for colon cancer.

OBJECTIVE/BACKGROUND: This study aimed to analyze the hypothesis that increased percentage drop in serum CEA post curative resection for colon cancer is associated with improved survival. METHODS: Five hundred thirty three patients who underwent colon resection with a curative intent were retrospectively analyzed for their pre- and postoperative CEA levels. The disease-free and overall survival curves were calculated using Kaplan Meier analysis to evaluate cancer related outcomes. For multivariate analysis, the Cox regression model was used. RESULTS: The estimated 5-year overall survival for the preoperative serum CEA > 5 ng/mL group with respect to a postoperative CEA level drop rate of 40%, 50% and 60% were 72.9%, 80.9% and 81.8%, respectively. The estimated 5-year overall survival for the preoperative serum CEA ≤ 5 ng/mL group with respect to each postoperative CEA level drop rate were 86.6%, 97.1% and 97.7%, respectively (P = 0.257, P = 0.092 and P = 0.073, respectively). The prognostic factors for poor survival were the depth of invasion (p = 0.042, hazard ratio: 2.617, 95% CI = 1.021-3.012) and lymph node metastasis (p = 0.008, hazard ratio: 2.249, 95% CI = 1.231-4.111). A 60% drop of the CEA level was an independent prognostic factor for survival (p = 0.001, hazard ratio: 2.954, 95% CI = 1.686-5.176) for patients with a preoperative CEA level > 5 ng/mL. CONCLUSION: Determining the preoperative CEA level and the early postoperative percent drop of the serum CEA level may be a helpful factor for the prognosis of colon cancer patients. However, the percent drop from the pre to postoperative CEA level from the normal range was not associated with survival difference.

Splenic abscess: a single institution study and review of the literature.

PURPOSE: The aim of this study was to review our experience with splenic abscesses, with respect to the relevant aspects of splenic abscesses and treatment outcomes. MATERIALS AND METHODS: We reviewed the cases of 18 patients who had splenic abscesses and who were treated at our hospital from November 1993 to December 2008. RESULTS: The most common symptom at presentation was abdominal pain in 12 patients (66.7%). The median duration from symptom onset until establishment of a diagnosis was 22 days. Streptococcus viridans was the most common pathogen (27.8%), follow by Klebsiella pneumoniae (22.2%). The mortality rate during the inpatient period and the previous 90 days was 16.6%. Three of four patients with Klebsiella pneumoniae showed a single abscess pocket. Four patients (22.2%) underwent percutaneous drainage, eight (44.5%) received antibiotic treatment only and six (33.3%) underwent splenectomy. CONCLUSION: There is no gold standard for treating splenic abscesses. Treatment should be customized for each patient.

Primary malignant mesothelioma developed in liver.

The following reports a rare case of primary localized malignant mesothelioma of the liver. A 53-year-old man with no history of exposure to asbestos was admitted to our department for evaluation of incidentally detected liver mass. Computed tomography and hepatic angiogram showed a tumor at the dome of the liver, which was fed mainly through the inferior phrenic artery. The mass was resected, including a portion of the diaphragm. Microscopically, the tumor was composed of cord-like or trabecular arrangements of epithelioid cells having abundant eosinophilic cytoplasm and prominent nucleoli. Immunohistochemically, the tumor cells were strongly positive for calretinin and cytokeratin 5 and negative for hepatocyte markers. These findings were consistent with our diagnosis of epithelioid mesothelioma. A local recurrence was noted 15 months after surgery, which was treated by radiofrequency ablation. At 23 months after initial surgery, locally recurrent masses with direct invasion of the diaphragm and a solitary intrahepatic metastasis were noted, which was treated by partial excision of the diaphragm with intraoperative RFA after transarterial chemoembolization.

Hepatic vein anatomy of the medial segment for living donor liver transplantation using extended right lobe graft.

Hepatic vein anatomy (V4) of the medial segment (S4) has been a matter of concern since introduction of extended right lobe (ERL) graft. To assess risk of hepatic venous congestion (HVC) in ERL donors, we tried to newly classify V4 anatomy. We analyzed V4 anatomy of 328 living donor livers by using 3-dimensional reconstruction (3-DR) and volumetry of computed tomography (CT). Variations of V4 were divided into type A (middle hepatic vein [MHV] dominant: n = 142, 43.3%), type B (MHV-dominant, but enabling preservation of dorsal V4 branch [V4b]: n = 40, 12.2%), type C (mixed: n = 92, 28%), and type D (left hepatic vein dominant: n = 54, 16.5%). We analyzed the amount of HVC at S4 in 143 donor livers of right lobe (RL) and ERL grafts. Occlusion of MHV trunk induced HVC equivalent to 85.2%, 85.4%, 55.2%, and 35.4% of S4 volume and 34%, 33.9%, 20.3%, and 14.2% of left liver volume in livers of types A, B, C, and D, respectively. Tailored V4b preservation reduced HVC significantly in type B livers. Considering that functional capability may be decreased in HVC portion, functional hepatic resection rate (FHRR) of ERL graft procurement ranged as follows: 62.3%-75% in type A; 62.2%-75% and 62.2%-68.7% in type B with and without V4b preservation, respectively; 63.2%-70.7% in type C; and 61.8%-67.2% in type D. These results support the theory that these categories of V4 types are closely correlated with potential amount of HVC at S4, reflect the possibility of V4b preservation, and are compatible with CT findings. We believe that this V4 classification is applicable to assess donor V4 anatomy in practice.

[Therapeutic effect of adefovir dipivoxil on recurrent or de novo infection of hepatitis B virus after liver transplantation: a preliminary report].

BACKGROUND/AIMS: Anti-viral therapy using hepatitis B immune globulin and lamivudine could not prevent HBV recurrence after liver transplantation (LT) completely. Adefovir dipivoxil is a acyclic nucleotide phosphate analogue and known to have potent anti-HBV effect. In this study, we analyzed the therapeutic effect of adefovir for recurrent or de novo HBV infection after LT. METHODS: From December 2002 to October 2004, adefovir was administered in 12 post-LT patients of HBV infection (11 recurrent and 1 de novo infection). In these patients, lamivudine and other combined therapies were used before the introduction of adefovir. Thereafter, adefovir combined with lamivudine was administered to all patients. RESULTS: The duration of adefovir administration was 5.5-18 (median, 15.5) months. The median values of serum AST and ALT levels were significantly reduced from 86+/-80 IU/L and 140+/-103 IU/L, respectively before the adefovir administration to 42+/-19 IU/L and 38+/-33 IU/L after 2 months of administration. This trend of improved liver function persisted throughout the follow-up period. HBeAg seroconversion was achieved in 4 of 10 patients (40%) and HBsAg seroconversion was observed in 1 of 10 patients (10%). HBV DNA levels have decreased to undetectable levels by hybridization assay in 6 of 7 patients within the first 2 months of therapy. Nephrotoxicity and hypophosphatemia were not found in all of these patients. CONCLUSIONS: Based on this preliminary result, adefovir dipivoxil seems to be an effective and safe antiviral agent leading to viral inhibition and clinical improvement in post-LT patients with recurrent or de novo HBV infection.

Simplified standardized technique for living donor liver transplantation using left liver graft plus caudate lobe.

Concomitant resection of the caudate lobe (CL) would increase the liver mass in the left liver graft. We tried to define a simplified standardized technique for adult living donor liver transplantation using the extended left lobe (ELL) plus CL (ELLC) through a prospective study of 27 consecutive ELLC graft cases in 2003. Donor CL was dissected toward the 10 o'clock direction and transected at the midpoint between the trunks of the right hepatic vein (RHV) and the middle hepatic vein (MHV). This orthodox transection was performed in 18 cases, but the transection plane was moved left in 9 cases. Compared with conventional left liver implantation, there was no additional reconstruction except for single revascularization of the largest short hepatic vein of the CL (V1) in 21 cases. On 1-week computed tomography (CT) images, the perfusion states of the CL portion were good in 15 cases, fair in 7 cases, and poor in 5 cases. Regeneration of the CL portion during the 1st week was +43%, +18%, and -10% in the good, fair, and poor perfusion groups, respectively. There were positive correlations among the perfusion state of the CL, the location of the CL transection plane, and the width of the CL portion that was attached to the left liver graft. CL implantation resulted in a mean gain of graft mass by 5.9% in the left liver at the time of operation and by 3.9% after 1 week. There were no donor complications, and 25 recipients (93%) survive to date. In conclusion, this simplified standardized technique was feasible for most of the living donor livers and required only 1 additional reconstruction of the V1.

Donor selection for procurement of right posterior segment graft in living donor liver transplantation.

The right posterior segment (RPS) graft was introduced to overcome graft-size mismatch when the donor liver demonstrates a disproportionately small left lobe (LL). As variants of liver anatomy seemed to be related to the feasibility of RPS graft procurement, in 2003, we performed a prospective study to assess its feasibility in 197 consecutive living donors. Variants of the portal vein (PV) were classified as type I (bifurcation), II (trifurcation), and III (independent RPS PV branching from main PV). The right hepatic artery, vein, and bile duct were also classified according to their branching pattern and location. PV variations were type I in 157 (79.7%) donors, type II in 15 (7.6%) donors, and type III in 25 (12.7%) donors. Mean volume proportion of LL plus caudate lobe was 35.3 +/- 3.8% (range 24-4) of the whole liver volume (WLV). On exclusion of donors with LL greater than 35% of WLV, there were 14 (7.1%) donors revealing RPS greater than LL by over 3% of WLV. Of these 14 donors, 3 had type I PV with artery or bile duct anatomy not suitable for RPS procurement. One donor with type II PV and 9 out of 10 donors with type III PV met the anatomical conditions for RPS graft procurement. With the exclusion of caudate lobe volume, LL volume became less than 30% of WLV in all of these 14 donors. We successfully procured 3 RPS grafts, all with type III PV, out of 197 consecutive living donors. In conclusion, successful RPS graft procurement is highly possible, only when LL is disproportionately small (<30% of WLV) and the PV variant is type III.