Anticancer Effect of Statins in Patients Undergoing Liver Transplantation for Hepatocellular Carcinoma.

The anticancer effect of statins is drawing attention. However, it is unclear whether statin use reduces the risk of hepatocellular carcinoma (HCC) recurrence in patients who undergo liver transplantation (LT) for HCC. Consecutive patients who underwent LT for HCC between 1995 and 2019 were enrolled. The effects of statins on HCC recurrence and mortality were compared between statin user and statin nonuser groups. We performed the analyses in a variety of ways, including inverse probability treatment weighting (IPTW) methods to balance any confounders and the landmark method to avoid immortal time bias. A total of 430 patients were enrolled, among whom 323 (75.1%) were statin nonusers and 107 (24.9%) were statin users. During a median of 64.9 months (IQR, 26.1-122.6 months) of follow-up, 79 patients (18.4%) had HCC recurrence and 111 (25.8%) died. Among those who died, 53 (47.7%) were identified as HCC-related mortalities. Statin use was a predictor of HCC recurrence (adjusted hazard ratio [HR], 0.3; 95% confidence interval [CI], 0.1-0.6; P = 0.002), all-cause mortality (adjusted HR, 0.3; 95% CI, 0.2-0.5; P < 0.001), and HCC-related mortality (adjusted HR, 0.4; 95% CI, 0.2-0.9; P = 0.03). The effects of statin use on clinical outcomes were also identified through IPTW analysis. There was a dose-dependent relationship between statin use and HCC recurrence. The anticancer effect of statins on HCC recurrence was consistently significant across multivariable-stratified and sensitivity analyses. Statin use significantly reduced the risk of HCC recurrence and improved the survival of patients who underwent LT for HCC.

Comparative long-term outcomes for pancreatic volume change, nutritional status, and incidence of new-onset diabetes between pancreatogastrostomy and pancreatojejunostomy after pancreaticoduodenectomy.

BACKGROUND: The difference in volume change in a pancreatic remnant according to the type of pancreaticoenterostomy after pancreaticoduodenectomy (PD) for long-term follow-up is unknown. Also, there are few studies that evaluate the difference in general nutritional status and pancreatic endocrine function, including new-onset diabetes mellitus (NODM) depending on the type of pancreaticoenterostomy. This study aimed to compare serial pancreatic volume changes in pancreatic remnants between pancreatogastrostomy (PG) and pancreatojejunostomy (PJ) after PD and to evaluate the difference in general nutritional status and incidence of NODM between PG and PJ. METHODS: This study enrolled 115 patients who had survived for more than 3 years after PD. They were divided into the PG group and the PJ group. Their clinicopathologic factors were collected and analyzed. We calculated serial pancreas volume and pancreatic duct size precisely from preoperative stage to 5 years after surgery by image-processing software specifically designed for navigation and visualization of multimodality and multidimensional images. Consecutive changes of albumin and body mass index (BMI) as related to general nutritional status were compared between the PG and PJ groups. To evaluate the incidence and risk factors of NODM following PD, subgroup analysis was performed in 88 patients who did not have diabetes preoperatively. RESULTS: Most patient demographics were not significantly different between the PG group (n=45) and PJ group (n=70). There was no significant difference in volume reduction between the groups from postoperative 1 month to 5 years (PG group -18.21±14.66 mL versus PJ group -14.43±13.05 mL, P=0.209). But there was a significant difference in increased pancreatic duct size between the groups from postoperative 1 month to 5 years (PG group 1.66±2.20 mm versus PJ group 0.54±1.54 mm, P=0.007). There was no significant difference in the increase of total serum albumin between the groups for 5 years after surgery (PG group 0.51±0.47 g/dL, 14.3% versus PJ group 0.42±0.60 g/dL, 11.3%, P=0.437). There was also no significant difference in BMI decrease between the groups (PG group -1.13±3.12, -4.9% versus PJ group -1.97±2.01, -8.7%, P=0.206). On the whole, NODM was diagnosed in 19 patients out of the 88 patients (21.6%) who did not have DM preoperatively. The incidence of NODM was not significantly different between the groups (PG group 21.6% versus PJ group 21.5%, P=0.995). In addition, pancreaticoenterostomy was not an independent risk factor for NODM by logistic regression analysis (odds ratio, 0.997, 95% CI: 0.356-0.2.788, P=0.995). No other risk factors for NODM were found. CONCLUSIONS: PG and PJ following PD induced similar pancreatic volume reduction during long-term follow-up. There was no difference in general nutritional status or incidence of NODM between the groups after PD.

Impact of the Reconstruction Material on the Patency of Middle Hepatic Vein in Living Donor Liver Transplantation Using the Right Liver.

BACKGROUND: A right liver graft with middle hepatic vein (MHV) reconstruction is the standard graft for adult-to-adult living donor liver transplantation (LDLT). The patency of reconstructed MHV affects the recovery and regeneration of graft. The aim of the study is to evaluate the patency rate of reconstructed MHV according to the reconstruction material in LDLT using the right liver. METHODS: The data was collected retrospectively on 521 patients who underwent LDLT with right liver graft form August 2003 to December 2012 at the Seoul St. Mary's Hospital in Seoul. Two serial comparisons were performed. At first, patients were divided into 2 groups: biologic graft group (n = 252) and synthetic graft group (n = 177). Second, patients were divided into 6 groups: No MHV reconstruction (n = 92); MHV was reconstructed by greater saphenous vein (GSV) (n = 20); recipient's portal vein (PV) (n = 219); cryopreserved iliac artery (CIA) (n = 2); cryopreserved iliac vein (CIV) (n = 11); polytetrafluoroethylene (PTFE) graft (n = 105); and polyethylene terephthalate (PETE) graft (n = 72). We compared the patency of reconstructed MHV among these groups by computed tomography angiography at 7 days, 20 days, 90 days, and 1 year. RESULTS: At the first comparison, the patency rate of the biologic graft group on the seventh postoperative day was 61.9%, and the synthetic graft group was 72.4% (P = .029). At postoperative 1 year, the patency rate of the biologic graft group was 42.9%, and the synthetic graft group was 24.1% (P = .001). At the second comparison, the MHV patency of GSV, PV, CIA, CIV, PTFE, and PETE was 65.0%, 62.5%, 50%, 63.6%, 75%, 72% on the seventh postoperative days (P = .318); 60%, 57.1%, 50%, 54.5%, 69%, 55.6% on the 20th postoperative days (P = .444); 40%, 48.8%, 50%, 27.3%, 47%, 34.1% on the 90th postoperative days (P = .294); and 30%, 45.2%, 50%, 27.3%, 27%, 26.4% at 1 postoperative year (P = .008). CONCLUSION: Although there was no statistical difference in comparison of each material, there were significant differences in MHV patency rates between the biologic and the synthetic group. Therefore, the synthetic graft could be considered in living donor liver transplantation with MHV reconstruction.

Laparoscopic end-to-end biliary reconstruction with T-tube for transected bile duct injury during laparoscopic cholecystectomy.

PURPOSE: This report describes the laparoscopic end-to-end biliary reconstruction with T-tube for transected bile duct injury (BDI) during laparoscopic cholecystectomy. METHODS: We performed a retrospective descriptive analysis for all patients with a transected BDI at a single institution. We collected and analyzed data for injury site and type, reconstruction methods, conversion rate, previous intervention, and outcomes. RESULTS: Between January 2014 and December 2017, 2,901 patients underwent laparoscopic cholecystectomy at a single institution. Among them, 8 patients experienced a transected BDI during laparoscopic cholecystectomy, so the surgeon performed laparoscopic end-to-end biliary reconstruction with T-tube. Our patient series consisted of 6 women (75%) and 2 men (25%) with a mean age of 48.3 years (median, 49 years; range, 29-77 years). Two cases were converted to open surgery. The most common injured site was the common bile duct (5 of 8, 62.5%). The most common injury type, using Bismuth's classification system, was type I (3 of 8, 37.5%). The mean operating time was 136.8 minutes (median, 135.0 minutes; range, 0-180.0 minutes). The mean hospital stay was 7.0 days (median, 4.5 days, range: 3.0-21.0 days). The mean follow-up was 36.4 months (median, 34.0 months; range, 16.0-63.0 months). We observed one postoperative complication during the follow-up period. The patient had an anastomosis site leakage and was cured after reoperation. CONCLUSION: Laparoscopic end-to-end biliary reconstruction with T-tube for transected BDI during laparoscopic cholecystectomy seems to be safe and feasible in selected patients. However, long-term follow-up to identify complications from bile duct stricture remains important.

Fraxinellone inhibits inflammatory cell infiltration during acute pancreatitis by suppressing inflammasome activation.

Inflammasomes promote the production of pro-inflammatory cytokines, such as interleukin (IL)-1ß and IL-18, which are the representative mediators of inflammation. Abnormal activation of inflammasomes leads to the development of inflammatory diseases such as acute pancreatitis (AP). In this study, we demonstrate the inhibitory effects of a new natural compound fraxinellone on inflammasome formation and examine the role of inflammasomes in a mouse model of AP. AP was induced with hourly intraperitoneal injections of supramaximal concentrations of the stable cholecystokinin analogue cerulein (50 µg/kg) for 6 h. Mice were sacrificed 6 h after the final cerulein injection. Blood and pancreas samples were obtained for further experiments. Intraperitoneal injection of fraxinellone significantly inhibited the pancreatic activation of multiple inflammasome molecules such as NACHT, LRR and PYD domains-containing protein 3 (NLRP3), PY-CARD, caspase-1, IL-18, and IL-1ß during AP. In addition, fraxinellone treatment inhibited pancreatic injury, elevation in serum amylase and lipase activities, and infiltration of inflammatory cells such as neutrophils and macrophages but had no effect on pancreatic edema. To investigate whether inflammasome activation leads to the infiltration of inflammatory cells, we used parthenolide, a well-known natural inhibitor, and IL-1 receptor antagonist mice. The inhibition of inflammasome activation by pharmacological/or genetic modification restricted the infiltration of inflammatory cells, but not edema, consistent with the results observed with fraxinellone. Taken together, our study highlights fraxinellone as a natural inhibitor of inflammasomes and that inflammasome inhibition may lead to the suppression of inflammatory cells during AP.

Dual-Incision Laparoscopic Spleen-Preserving Distal Pancreatectomy: Merits Compared to the Conventional Method.

BACKGROUND: Herein, we assess the safety and feasibility of dual-incision laparoscopic spleen-preserving distal pancreatectomy (DILSPDP) through lateral approach with reduced trocars for benign and low-grade malignancy in pancreas tail. We compare DILSPDP with surgical outcomes of conventional laparoscopic spleen-preserving distal pancreatectomy (LSPDP). METHODS: Patients with benign pancreas tail mass that had been scheduled for LSPDP were selected to undergo DILSPDP. These patients had spleen-preserving distal pancreatectomy with the dissection in lateral-to-medial fashion using a multichannel trocar in the right lateral decubitus position of patient. We compared the demographics and operative outcomes of DILSPDP with those of conventional LSPDP which was performed with dissection in medial-to-lateral fashion using four or five trocars in supine position. RESULTS: Twenty two cases of DILSPDP and 26 cases of conventional LSPDP were reviewed. There was no difference in terms of demographic features including diagnosis or tumor size, although the location of the tumor was fundamentally different between the two groups. Significantly shorter operative times and reduced blood loss were observed in DILSPDP group (p = 0.004 and 0.011, respectively) and the preservation of splenic vessels was more successful with DILSPDP than conventional surgery (95.5% vs. 65.4%, p = 0.013). CONCLUSIONS: DILSPDP appears to be a feasible method of spleen-preserving distal pancreatectomy for benign or low-malignancy of pancreas tail and is accompanied by advantages in terms of splenic vessel preservation and reduced parietal trauma.

Clinical outcome of 1,000 consecutive cases of liver transplantation: a single center experience.

PURPOSE: The aim of this study was to analyze survival outcomes in 1,000 consecutive liver transplantations (LTs) performed at a single institution from 1993 to April 2017. METHODS: The study population was divided into 2 groups based on donor type: deceased donor LT (DDLT; n = 181, 18.1%) and living donor LT (LDLT; n = 819; 81.9%), and into 3 periods based on the number of cases (first 300 cases, middle 300 cases, last 400 cases). RESULTS: Infection was the most common cause of death, accounting for 34.8% (95 of 273). Mortality due to hepatocellular carcinoma recurrence occurred most frequently between 1 and 5 years after transplantation. Mortality rate by graft rejection was highest between 5 and 10 years after transplantation. And mortality by de novo malignancy occurred most frequently after 10 years after transplantation. The patient survival rates for the entire population at 5 and 10 years were 74.7%, and 68.6%, respectively. There was no difference in survival rate between the LDLT and DDLT groups (P = 0.188). Cause of disease, disease severity, case period, and retransplantation had a significant association with patient survival (P = 0.002, P = 0.031, P = 0.003, and P = 0.024, respectively). CONCLUSION: Surgical techniques and perioperative management for transplant patients have improved and undergone standardization. Controlling perioperative infection and managing patients with HCC as LT candidates will result in better outcomes.

Clinical Course of Hepatic Artery Thrombosis After Living Donor Liver Transplantation Using the Right Lobe.

Hepatic artery thrombosis (HAT) can result in biliary tree necrosis and graft loss, necessitating retransplantation. The most effective treatment approach is still controversial. This study was performed to review the outcomes of HAT after living donor liver transplantation (LDLT) and to clarify the feasibility of different strategies. From May 1996 to August 2017, LDLT using the right lobe was performed in 827 adult patients in our center. Our technique of hepatic artery (HA) reconstruction is end-to-end anastomosis under a microscope (10×). Diagnosis of HAT was performed using Doppler sonography and computed tomography (CT) angiography. HAT was initially treated with surgical or endovascular procedure, and retransplantation was considered according to the graft condition. Among the 827 cases of LDLT using the right lobe, HAT occurred in 16 (1.9%) cases within 1 month after transplantation. Within the first week, 7 of these HAT cases (43.8%) occurred (early HAT), while the remaining 9 cases (56.2%) occurred between the first week and 1 month (late HAT). The incidence of graft failure was high in early HAT (42.9%), and the frequency of biliary complications was high in late HAT (77.8%). The success rate of HA recanalization was 62.5% (10/16): 100% (5/5) after reoperation and 45.5% (5/11) after the endovascular procedure. Of the patients in whom treatment failed in late HAT (n = 5), 4 underwent neovascularization during observation. A total of 5 patients underwent graft failure, and 3 of these patients underwent repeat liver transplantation (LT). Mortality occurred in 3 patients, including 1 in the surgical group and 2 in the endovascular group. In conclusion, early diagnosis and aggressive treatment of HAT are necessary to avoid graft failure, and the choice of treatment depends on various factors. Although further studies are required, early HAT requires preparation for graft failure, while late HAT requires treatment for biliary complications.

Comparison of the long-term efficacy and safety of generic tacrolimus, Tacrobell, with Prograf in liver transplant recipients.

INTRODUCTION: The purpose of this study was to compare the safety and efficacy of generic tacrolimus (Tacrobell [TCB]) and a reference tacrolimus (Prograf [PGF]) in liver transplant recipients. PATIENTS AND METHODS: We retrospectively analyzed 167 patients who used TCB or PGF between January 2009 and March 2016 for >1 year (TCB group, n=86; PGF group, n=81). To assess the efficacy and safety of TCB, we evaluated the relationship between drug dose and trough level, survival, rejection, infection, kidney function, and side effects. RESULTS: There was no difference in the preoperative demographics between the two groups. Moreover, there was no difference in the drug dose and trough level between the groups at 1 week after surgery. Coefficient of variation (CV) values were obtained at the drug trough level for each patient and no differences in CV values were identified within 1 year (p=0.587) and up to 5 years (p=0.824) in both groups. Rehospitalization (p=0.1) and total rejection (p=0.915) did not differ between the two groups, but the rejection severity, recorded as the rejection activity index value, was worse in the PGF group (p=0.039). No difference was found in the infection rate (p=0.818), and with regard to nephrotoxicity, there was no difference in the rate of patients with chronic kidney disease stage 3 and above during the follow-up period. No differences were found between the two groups in terms of drug side effects and adverse events. CONCLUSION: The generic tacrolimus, TCB, is a comparable alternative to the original tacrolimus, PGF, as a main immunosuppressive drug for liver transplantation.

Clinical advantages of single port laparoscopic hepatectomy.

AIM: To evaluate the clinical advantages of single-port laparoscopic hepatectomy (SPLH) compare to multi-port laparoscopic hepatectomy (MPLH). METHODS: We retrospectively reviewed the medical records of 246 patients who underwent laparoscopic liver resection between January 2008 and December 2015 at our hospital. We divided the surgical technique into two groups; SPLH and MPLH. We performed laparoscopic liver resection for both benign and malignant disease. Major hepatectomy such as right and left hepatectomy was also done with sufficient disease-free margin. The operative time, the volume of blood loss, transfusion rate, and the conversion rate to MPLH or open surgery was evaluated. The post-operative parameters included the meal start date after operation, the number of postoperative days spent in the hospital, and surgical complications was also evaluated. RESULTS: Of the 246 patients, 155 patients underwent SPLH and 91 patients underwent MPLH. Conversion rate was 22.6% in SPLH and 19.8% in MPLH (P = 0.358). We performed major hepatectomy, which was defined as resection of more than 2 sections, in 13.5% of patients in the SPLH group and in 13.3% of patients in the MPLH group (P = 0.962). Mean operative time was 136.9 ± 89.2 min in the SPLH group and 231.2 ± 149.7 min in the MPLH group (P < 0.001). The amount of blood loss was 385.1 ± 409.3 mL in the SPLH group and 559.9 ± 624.9 mL in the MPLH group (P = 0.016). The safety resection margin did not show a significant difference (0.84 ± 0.84 cm in SPLH vs 1.04 ± 1.22 cm in MPLH, P = 0.704). Enteral feeding was started earlier in the SPLH group (1.06 ± 0.27 d after operation) than in the MPLH group (1.63 ± 1.27 d) (P < 0.001). The mean hospital stay after operation was non-significantly shorter in the SPLH group than in the MPLH group (7.82 ± 2.79 d vs 7.97 ± 3.69 d, P = 0.744). The complication rate was not significantly different (P = 0.397) and there was no major perioperative complication or mortality case in both groups. CONCLUSION: Single-port laparoscopic liver surgery seems to be a feasible approach for various kinds of liver diseases.

Prognostic Prediction Models for Resection of Large Hepatocellular Carcinoma: A Korean Multicenter Study.

BACKGROUND: We developed a prognostic prediction model (PPM) using 4 factors for hepatic resection (HR) of large hepatic cellular carcinoma (HCC). Multiplication of α-fetoprotein (AFP), des-γ-carboxy prothrombin, and tumor volume (TV) (ADV score) is a surrogate marker for post-resection prognosis. This study intended to validate the predictive power of 4-factor PPM and to develop new ADV score-based PPM. METHODS: A total of 526 patients who underwent HR for solitary HCC ≥ 8 cm were selected from 9 Korean institutions between 2008 and 2014. RESULTS: Median tumor diameter and TV were 11.0 cm and 398 mL, respectively. Tumor recurrence and patient survival rates were 53.0 and 78.4% at 1 year and 70.2 and 49.3% at 5 years, respectively. Independent risk factors for both tumor recurrence and patient survival included AFP ≥ 100 ng/mL, hypermetabolic FDG-positron emission tomography (PET), microvascular invasion and satellite nodules, which comprised 4 factors of the PPM. Five subgroups based on the number of involved risk factors exhibited significant differences in tumor recurrence and patient survival. ADV score cutoff was set at 7log (ADV7log) after cluster prognostic analysis. Patient grouping according to combination of ADV7log and FDG-PET findings (ADV7log-PET) exhibited significant differences in tumor recurrence and patient survival, comparable to those of the 4-factor PPM. CONCLUSIONS: Two PPMs using 4 risk factors and ADV7log-PET could reliably predict the risk of early HCC recurrence and long-term survival outcomes in patients who underwent HR for large HCC. We believe that these PPMs can guide surgical treatment for large HCCs from preoperative HR planning to post-resection follow-up.

Deep gray matter iron measurement in patients with liver cirrhosis using quantitative susceptibility mapping: Relationship with pallidal T1 hyperintensity.

BACKGROUND: The liver is a central organ for the metabolism of iron and manganese and the places where those metals are commonly deposited overlap in the brain. PURPOSE/HYPOTHESIS: To elucidate the relationship between pallidal T1 hyperintensity and iron deposition in the deep gray matter of liver cirrhosis patients using quantitative susceptibility mapping (QSM). STUDY TYPE: Retrospective case-control study SUBJECTS: In all, 38 consecutive liver cirrhosis patients who received brain magnetic resonance imaging (MRI) as pretransplant evaluation. FIELD STRENGTH/SEQUENCE: QSM was reconstructed from 3D multi- or single-echo phase images at 3T. T1 -weighted images were used for the assessment of pallidal hyperintensity and pallidal index (PI). ASSESSMENT: Patients were divided into two groups according to the presence of pallidal hyperintensity by consensus of two radiologists. Susceptibility values were acquired for five deep gray matter structures. STATISTICAL TEST: QSM measures were compared between two groups using the t-test. We also calculated Pearson correlations between QSM measures and PI. RESULTS: In all, 26 patients showed pallidal hyperintensity (T1 h group) and 12 did not (T1 n group). The susceptibility of the globus pallidus (GP) in the T1 h group (120.6 ± 38.1 ppb) was significantly lower than that in the T1 n group (150.0 ± 35.2, P = 0.030). The susceptibility of the dentate nucleus (DN) in the T1 h group (88.1 ± 31.0) was significantly lower than that in the T1 n group (125.6 ± 30.6, P = 0.001). Negative correlation between the susceptibility of GP (r = -0.37, P = 0.022) and the PI, and between DN (r = -0.43, P < 0.001) and the PI was found. DATA CONCLUSION: Liver cirrhosis patients with pallidal T1 hyperintensity had lower susceptibility values in the GP and DN than those without it. This suggests a possible interaction between iron and manganese in the brains of liver cirrhosis patients. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1342-1349.

Quantitative assessment of liver fibrosis using shore durometer.

PURPOSE: The purpose of the present study was to investigate whether hardness of liver surface correlated with degree of liver fibrosis, and its association with posthepatectomy liver failure (PHLF). METHODS: A shore durometer was used to measure hepatic hardness in 41 patients with hepatocellular carcinoma (HCC) and in 10 patients with normal liver. We investigated how hepatic hardness correlates with various values indicating the degree of liver fibrosis, and how it correlates with PHLF. RESULTS: In the normal liver group, the surface shore units (SU) was 15.06 ± 2.64. In the HCC group, there was a correlation between surface SU and preoperative results indicating liver fibrosis. Among patients with PHLF after resecting over 3 segments, the surface SU of patients with grade A PHLF was 21.85 ± 5.63, and the surface SU of patients with grade C PHLF was 35.75 ± 9.26. In patients with PHLF after resecting 2 or less segments, the surface SU of patients with PHLF grade A was 20.95 ± 5.18, and the surface SU of patients with PHLF grade B was 31.60 ± 5.57. In predicting PHLF, surface SU was more effective than preoperative platelet count, spleen volume, or liver fibrosis index. CONCLUSION: Hepatic hardness measured by the shore durometer was correlated with the degree of liver fibrosis. Liver surface SU was a more effective parameter for predicting PHLF, as compared to other indicators evaluated before hepatectomy. The decision to perform major hepatectomy should be reconsidered in cases with a liver surface SU of >30.

A Multicenter Phase III Study to Evaluate the Efficacy and Safety of Hepabulin, a New Hepatitis B Immunoglobulin, in Liver Transplantation Recipients with Hepatitis B.

BACKGROUND This study was performed to evaluate the effects and stability of the new hepatitis B immunoglobulin (HBIG), Hepabulin, in patients undergoing liver transplantation for hepatitis B. MATERIAL AND METHODS A total of 87 patients undergoing liver transplantation for hepatitis B-related liver disease were enrolled in this multicenter, phase III, open-label, single-arm study. Seventy (80.5%) of the 87 enrolled patients completed the study during the 52-week study period. Hepabulin (10,000 units) was intravenously injected intraoperatively, daily for 1 week, weekly for 1 month, and then once per month. Hepabulin was used as monotherapy without antiviral agents. Hepatitis B recurrence was defined as conversion from negativity for surface antigen after HBIG administration to positivity. RESULTS There were no cases of hepatitis B recurrence during the 52-week observation period. A total of 876 adverse events (AEs) that occurred during the study period were observed in 83 (95.4%) of 87 patients, and serious AEs were seen in 119 cases in 44 (50.6%) of the 87 patients. None of the AEs showed a relationship with this drug. Hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) rapidly disappeared within 1 week after HBIG administration, but hepatitis B virus (HBV) DNA persisted for up to 8 weeks after surgery, which was related to HBV viral load. Hepatitis B surface antibody (HBsAb) was correlated with HBIG (Hepabulin) dose. CONCLUSIONS The new HBIG, Hepabulin, was shown to be safe and effective in preventing the recurrence of HBV after liver transplantation.

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.

Long-Term Outcome of Liver Resection Versus Transplantation for Hepatocellular Carcinoma in a Region Where Living Donation is a Main Source.

BACKGROUND The aim of this study was to define the best curative strategy in patients with hepatocellular carcinoma (HCC) in a hepatitis B virus (HBV)-endemic region where living donation dominates the type of cadaveric donation for liver transplantation (LT). MATERIAL AND METHODS A retrospective cohort comprised those patients whose clinical course could potentially be traced for at least 10 years. We found 262 HCC patients who had undergone curative surgical treatment from March 1997 to August 2006. Among these patients, 156 were treated with liver resection (LR) (R group) and 106 patients underwent LT (T group, 100 patients with living donor). Tumor characteristics, overall survival (OS), and recurrence-free survival (RFS) were analyzed. RESULTS Postoperative mortality was not significantly different between the groups, whereas recurrence rate during the study period (until August 2016) was higher in the R group (56% in the R group versus 19% in the T group, p<0.001). The 10-year and 15-year OS and RFS were better in the T group. Subgroup analysis with patients having solitary and £5 cm tumor by preoperative imaging showed that the 10-year and 15-year OS and RFS were much better in the T group, irrespective of their preoperative liver function defined by MELD score. In the T group, resection as the surgical procedure and tumor size on histology were poor prognostic factors for RFS. Importantly, this superiority of LT over LR in OS and RFS applied only to the patients with relatively low preoperative alpha-fetoprotein (AFP) levels (AFP <100 ng/mL), because patients with higher levels compared with lower levels of AFP tended to have more recurrent tumors after LT, but not in the case of LR during long-term follow-up. CONCLUSIONS Overall, LT was associated with better survival outcomes than resection in patients with HCC in Korea, where living donation is a main transplant source.

The clinical outcomes of patients with portal vein tumor thrombi after living donor liver transplantation.

The purpose of this study was to evaluate the feasibility of living donor liver transplantation for treatment of patients with hepatocellular carcinoma and segmental portal vein tumor thrombus (PVTT) below the second-order branch. Between January 2005 and December 2015, we retrospectively analyzed 242 patients in a control group (n = 184), a microvascular invasion (MVI) group (n = 24), and a PVTT group (n = 34). To assess the risks associated with PVTT, we evaluated recurrence, the disease-free survival (DFS) rate, the overall survival (OS) rate, and various other factors based on the characteristics of patients and tumors. Of the 242 patients, 5-year DFS and OS rates were 79.5% and 70.7%. A total of 34 (14.0%) patients had PVTT, of whom 7 had lobar PVTT in first-order branches. The control, MVI, and PVTT groups significantly differed in terms of tumor morphology (maximal and total diameters) and biology (alpha-fetoprotein [AFP] and protein induced by vitamin K absence or antagonist II). The control, MVI, and PVTT groups significantly differed in terms of the recurrence, DFS, and OS rates. Especially, lobar PVTT reduced the 5-year DFS and OS rates to dismal and 14.3%, respectively, but segmental PVTT was associated with favorable 5-year DFS and OS rates (63.9% and 50.3%, respectively). We found no statistically significant difference in the DFS and OS rates of patients with MVI alone and segmental PVTT alone. In patients in the segmental PVTT group with AFP levels of <100 ng/mL, the 5-year DFS and OS rates were 90.9% and 71.3%, respectively. In conclusion, a tumor thrombus in a lobar portal vein remains a contraindication to liver transplantation. However, a segmental PVTT is acceptable, especially when the AFP level is <100 ng/mL. Liver Transplantation 23 1023-1031 2017 AASLD.

Surgical results of reduced port laparoscopic adrenalectomy using a multichannel port in comparison with conventional laparoscopic adrenalectomy.

BACKGROUND: We introduced a modified laparoscopic technique, dual-incision laparoscopic adrenalectomy (DILA), using a newly designed multichannel trocar, and we evaluated its perioperative outcomes and operative costs and compared them to those of conventional laparoscopic adrenalectomy (CLA). METHODS: We retrospectively reviewed the medical records of 127 patients who underwent CLA with four trocars or DILA with two trocars at Seoul St. Mary's Hospital, Seoul, Korea between October 2007 and September 2014. We analyzed the patients' surgical outcomes and perioperative morbidities. RESULTS: DILA was performed in 45 patients and CLA in 82 patients. There were no significant differences in operative time (DILA: 77.1 ± 28.4 minutes vs. CLA: 76.6 ± 28.0 minutes, p = 0.595) or estimated blood loss during surgery (DILA: 150.0 ± 85.5 mL vs. CLA: 175.5 ± 50.5 mL, p = 0.697). There were no differences in postoperative hospital stay, visual analog scale pain score, or postoperative complication rates between the two groups. However, the operative cost was significantly lower in the DILA group (DILA 813,603 ± 48,600 Korean won vs. CLA 968,368 ± 56,456 Korean won, p < 0.001). CONCLUSION: This study demonstrated that DILA is a safe and feasible surgical approach for adrenal diseases. DILA may reduce the operative cost significantly compared with CLA.

Immunohistochemical markers for hepatocellular carcinoma prognosis after liver resection and liver transplantation.

AIM: There were differences in progression and prognosis of hepatocellular carcinoma (HCC) after surgery between liver resection (LR) and liver transplantation (LT). In this study, immunohistochemical (IHC) markers associated with the prognosis of HCC were assessed. METHODS: Data were collected from 167 patients who underwent LT (n=41) or LR (n=126) for HCC. IHC markers including alpha-fetoprotein (AFP), p53, Ki-67, cytokeratin 7 (CK7), and cytokeratin 19 (CK19) were compared between the treatment methods in tumor tissue. RESULTS: AFP- and p53-negative patients had a significantly higher survival rate than AFP- and p53-positive patients (AFP: disease-free survival [DFS] P=.006, overall survival [OS] P=.016; p53: DFS P=.005, OS P=.038) in the LR group. CK19 was related to DFS (P=.005), while CK7 (P=.014) and CK19 (P=.06) were related to OS in the LT group. When we combined factors that were significant in both groups (LR: AFP and p53, LT: CK7 and CK19), all-negative patients had a higher survival rate (LR: DFS P=.025, OS P=.043, LT: DFS P=.034, OS P=.008). CONCLUSION: p53 and AFP were predictors for poor prognosis of HCC after LR; CK7 and CK19 could be predictors for poor prognosis of patients with HCC after LT.