Long-Term Safety and Efficacy of Pure Laparoscopic Donor Hepatectomy in Pediatric Living Donor Liver Transplantation.

Laparoscopic living donor hepatectomy for transplantation has been well established over the past decade. This study aimed to assess its safety and feasibility in pediatric living donor liver transplantation (LDLT) by comparing the surgical and long-term survival outcomes on both the donor and recipient sides between open and laparoscopic groups. The medical records of 100 patients (≤17 years old) who underwent ABO-compatible LDLT using a left lateral liver graft between May 2008 and June 2016 were analyzed. A total of 31 donors who underwent pure laparoscopic hepatectomy and their corresponding recipients were included in the study; 69 patients who underwent open living donor hepatectomy during the same period were included as a comparison group. To overcome bias from the different distributions of covariables among the patients in the 2 study groups, a 1:1 propensity score matching analysis was performed. The mean follow-up periods were 92.9 and 92.7 months in the open and laparoscopic groups, respectively. The mean postoperative hospital stay of the donors was significantly shorter in the laparoscopic group (8.1 days) than in the open group (10.6 days; P < 0.001). Overall, the surgical complications in the donors and overall survival rate of recipients did not differ between the groups. Our data suggest that the laparoscopic environment was not associated with long-term graft survival during pediatric LDLT. In addition, the laparoscopic approach for the donors did not adversely affect the corresponding recipient's outcome. Laparoscopic left lateral sectionectomy for living donors is a safe, feasible, and reproducible procedure for pediatric liver transplantation.

Safety and feasibility of pure laparoscopic extended cholecystectomy: comparison with the open technique in a propensity analysis at a single center.

BACKGROUND: The aim of this study was to validate the safety and feasibility of pure laparoscopic extended cholecystectomy (LEC) by comparing the outcome with that of open extended cholecystectomy (OEC). Moreover, on the basis of our experience, we also aimed to investigate the learning curve of pure LEC. METHODS: This single-center study enrolled patients who were diagnosed primary gallbladder cancer with pathologically confirmed and underwent R0 resection with curative intent between January 2016 and December 2019. A total of 31 patients who underwent OEC and 17 patients who underwent LEC were selected. Propensity score matching analysis was performed in a 1:1 ratio using the nearest-neighbor matching method, and clinical information was retrospectively collected from medical records and analyzed. RESULTS: The postoperative hospital stay was statistically shorter in the LEC group (7 days) than in the OEC group (12 days). The overall surgical complication rate did not differ between the two groups. The 1- and 3-year disease-free survival rates were 82.4% and 82.4% in the OEC group and 94.2% and 71.5% in the LEC group, respectively (P = 0.94). Considering the correlation between the number of cumulative cases and the operation time and between the number of cumulative cases and the number of retrieved lymph nodes in the LEC group, as the cases were accumulated, both the operation time and the number of retrieved lymph nodes had a statistically significant correlation with the number of cases. CONCLUSIONS: LEC showed a significant advantage in terms of achieving shorter postoperative hospital stay and similar results to OEC with respect to overall complications and pathological outcomes. The present results confirm that laparoscopy can be considered a safe treatment for primary gallbladder cancer in selected patients.

Clinicopathological Differences in T2 Gallbladder Cancer According to Tumor Location.

We aimed to identify clinicopathological differences and factors affecting survival outcomes of stage T2a and T2b gallbladder cancer (GBC) and validate the oncological benefits of regional lymphadenectomy and hepatic resection in these patients. This single-center study enrolled patients who were diagnosed with pathologically confirmed T2 GBC and underwent curative resection between January 1995 and December 2017. Eighty-two patients with T2a and 50 with T2b GBCs were identified, and clinical information was retrospectively collected from medical records and analyzed. Five-year overall survival rates were 96.8% and 80.7% in T2a and T2b groups, respectively (P = .007). Three- and 5-year survival rates among all patients with T2 GBC without and with lymph node metastasis were 97.2% and 94.4% and 81.3% and 81.3%, respectively (P = .029). There was no difference in survival rates between the 2 groups according to whether hepatic resection was performed (P = .320). However, in the T2b group, those who underwent hepatic resection demonstrated a better survival rate than those who did not (P = .029). The T2b group had more multiple recurrence patterns than the T2a group, and the lymph nodes were the most common site in both groups. Multivariate analysis revealed that lymph node metastasis, vascular invasion, and tumor location were significant independent prognostic factors. Hepatic resection was not always necessary in patients with peritoneal-side GBC. Considering clinicopathological features and recurrence patterns, a systematic treatment plan, including radical resection and adjuvant treatment, should be established for hepatic-side GBC.

Clinicopathologic analysis of intraductal papillary neoplasm of bile duct: Korean multicenter cohort study.

BACKGROUND: IPNB is very rare disease and most previous studies on IPNB were case series with a small number due to low incidence. The aim of this study is to validate previously known clinicopathologic features of intraductal papillary neoplasm of bile duct (IPNB) based on the first largest multicenter cohort. METHODS: Among 587 patients previously diagnosed with IPNB and similar diseases from each center in Korea, 387 were included in this study after central pathologic review. We also reviewed all preoperative image data. RESULTS: Of 387 patients, 176 (45.5%) had invasive carcinoma and 21 (6.0%) lymph node metastasis. The 5-year overall survival was 80.9% for all patients, 88.8% for IPNB with mucosal dysplasia, and 70.5% for IPNB with invasive carcinoma. According to the "Jang & Kim's modified anatomical classification," 265 (68.5%) were intrahepatic, 103 (26.6%) extrahepatic, and 16 (4.1%) diffuse type. Multivariate analysis revealed that tumor invasiveness was a unique predictor for survival analysis. (p = 0.047 [hazard ratio = 2.116, 95% confidence interval 1.010-4.433]). CONCLUSIONS: This is the first Korean multicenter study on IPNB through central pathologic and radiologic review process. Although IPNB showed good long-term prognosis, relatively aggressive features were also found in invasive carcinoma and extrahepatic/diffuse type.

Impact of Inhalational Anesthetics on Liver Regeneration After Living Donor Hepatectomy: A Propensity Score-Matched Analysis.

BACKGROUND: Although desflurane and sevoflurane, the most commonly used inhalational anesthetics, have been linked to postoperative liver injury, their impact on liver regeneration remains unclear. We compared the influence of these anesthetics on the postoperative liver regeneration index (LRI) after living donor hepatectomy (LDH). METHODS: We conducted a retrospective chart review of 1629 living donors who underwent right hepatectomy for LDH between January 2008 and August 2016. The patients were divided into sevoflurane (n = 1206) and desflurane (n = 423) groups. Factors associated with LRI were investigated using multivariable logistic regression analysis. Propensity score matching analysis compared early (1 postoperative week) and late (within 1-2 months) LRIs and delayed recovery of hepatic function between the 2 groups. RESULTS: The mean early and late LRIs in the 1629 patients were 63.3% ± 41.5% and 93.7% ± 48.1%, respectively. After propensity score matching (n = 403 pairs), there were no significant differences in early and late LRIs between the sevoflurane and desflurane groups (early LRI: 61.2% ± 41.5% vs 58.9% ± 42.4%, P = .438; late LRI: 88.3% ± 44.3% vs 94.6% ± 52.4%, P = .168). Male sex (regression coefficient [ß], 4.6; confidence interval, 1.6-7.6; P = .003) and remnant liver volume (ß, -4.92; confidence interval, -5.2 to -4.7; P < .001) were associated with LRI. The incidence of delayed recovery of hepatic function was 3.6% (n = 29) with no significant difference between the 2 groups (3.0% vs 4.2%, P = .375) after LDH. CONCLUSIONS: Both sevoflurane and desflurane can be safely used without affecting liver regeneration and delaying liver function recovery after LDH.

Pure Laparoscopic Versus Open Right Hepatectomy for Hepatocellular Carcinoma in Patients With Cirrhosis: A Propensity Score Matched Analysis.

OBJECTIVE: We aimed to describe our experience with pure laparoscopic right hepatectomy (LRH) and to compare its outcomes with those of open right hepatectomy (ORH) in hepatocellular carcinoma (HCC) patients with liver cirrhosis. BACKGROUND: Laparoscopic liver resection has been reported as a safe and effective approach for the management of liver cancer; however, its outcomes have not been evaluated in a large cohort of HCC patients with liver cirrhosis. METHODS: We retrospectively reviewed the medical records of 152 patients who underwent pure LRH (n = 37) or ORH (n = 115) between June 2008 and July 2015 at the Asan Medical Center in Seoul, Korea. We performed 1:1 propensity score matching between the LRH and ORH groups. Subsequently, 33 patients were included in each group. RESULTS: There was no statistically significant difference between the LRH and ORH groups regarding the rate of complications (P = 0.053). However, the mean comprehensive complication index, which accounts for the severity of complications, was significantly lower in the LRH group (0.63 vs 4.42; P = 0.025). There were no significant differences between the LRH and ORH groups regarding 2-year disease-free survival rate or 2-year overall survival rate (P = 0.645 and P = 0.090, respectively). CONCLUSIONS: Even in patients with cirrhosis, pure LRH is not less safe than the traditional open approach. The oncological outcomes of HCC were also comparable between the two groups. In selected patients, pure LRH for HCC appears to represent a viable alternative to ORH.

Early outcomes of single-port robotic left lateral sectionectomy in patients with hepatic tumor.

Purpose: Laparoscopic left lateral sectionectomy (L-LLS) stands as a cornerstone procedure in hepatobiliary minimal surgery, frequently employed for various benign and malignant liver lesions. This study aimed to analyze the peri- and postoperative surgical outcomes of single-port robotic left lateral sectionectomy (SPR-LLS) vs. those of L-LLS in patients with hepatic tumors. Methods: From January 2020 through June 2023, 12 patients underwent SPR-LLS. During the same period, 30 L-LLS procedures were performed. In total, 12 patients in the robotic group and 24 patients in the laparoscopic group were matched. Results: When the SPR-LLS and L-LLS groups were compared, the operation time was longer in the SPR-LLS group with less blood loss and shorter hospital stay. Postoperative complications were observed in 3 patients in the L-LLS group (12.5%) and 1 patient in the SPR-LLS group (8.3%). Conclusion: SPR-LLS using the da Vinci SP system was comparable to laparoscopic LLS in terms of surgical outcomes. SPR-LLS was associated with lower blood loss and less postoperative length of stay compared to L-LLS. These findings suggest that left lateral sectionectomy is technically feasible and safe with the da Vinci SP system in select patients.

Feasibility and Efficacy of Single-Port Robotic Cholecystectomy Using the da Vinci SP® Platform.

Background: Single-incision laparoscopic cholecystectomy, first introduced in 1995, features acceptable cosmetic outcomes and postoperative pain control. The outcomes of single-port cholecystectomy by laparoscopy and robots were recently examined in many studies owing to surgeon and patient preference for minimally invasive surgery. A next-level da Vinci robotic platform was recently released. This study aimed to evaluate the feasibility and efficacy of robotic cholecystectomy (RC) using the da Vinci SP® system. Methods: In this retrospective observational single-center study, we analyzed the medical records of 304 patients who underwent RC between March 1, 2017 and May 31, 2021. Results: Of the 304 patients, the da Vinci Xi® (Xi) was used in 159 and the da Vinci SP® (SP) was used in 145. The mean operation time was 45.7 mins in the SP group versus 49.8 mins in the Xi group. The mean docking time of the SP group was shorter than that of the Xi group (5.7 min vs 8.8 min; p = 0.024). The mean immediate postoperative numerical rating scale (NRS) score was 4.0 in the SP group and 4.3 in the Xi group, showing a significant difference (p = 0.003). A separate analysis of only patients with acute cholecystitis treated with the da Vinci SP® showed that the immediate postoperative NRS score in the acute group was higher than that in the nonacute group. Conclusions: This study demonstrated acceptable results of single-site cholecystectomy using da Vinci SP®. Thus, pure single-port RC using the da Vinci SP® for various benign gallbladder diseases may be an excellent treatment option.

Case report of pure single-port robotic left lateral sectionectomy using the da Vinci SP system.

INTRODUCTION: Since its first appearance in the early 1990s, laparoscopic hepatic resection has become increasingly accepted and recognized as safe as laparotomy. The recent introduction of robotic surgery systems has brought new innovations to the field of minimally invasive surgery, such as laparoscopic surgery. The da Vinci line of surgical systems has recently released a true single-port platform called the da Vinci SP system, which has 3 fully wristed and elbowed instruments and a flexible camera in a single 2.5 cm cannula. We present the first case of robotic liver resection using the da Vinci SP system and demonstrate the technical feasibility of this platform. PATIENT CONCERNS AND DIAGNOSIS: A 63-year-old woman presented with elevated liver function test results and abdominal pain. Computed tomography (CT) and magnetic resonance cholangiopancreatography showed multiple intrahepatic duct stones in the left lateral section and distal common bile duct stones near the ampulla of Vater. INTERVENTIONS: The docking time was 8 minute. The patient underwent successful da Vinci SP with a total operation time of 135 minute. The estimated blood loss was 50.0 ml. No significant intraoperative events were observed. OUTCOMES: The numerical pain intensity score was 3/10 in the immediate postoperative period and 1/10 on postoperative day 2. The patient was discharged on postoperative day 5 after verifying that the CT scan did not show any surgical complications. CONCLUSION: We report a technique of left lateral sectionectomy, without the use of an additional port, via the da Vinci SP system. The present case suggests that minor hepatic resection is technically feasible and safe with the new da Vinci SP system in select patients. For the active application of the da Vinci SP system in hepatobiliary surgery, further device development and research are needed.

Prognostic value of the lymph node metastasis in patients with ampulla of Vater cancer after surgical resection.

BACKGROUNDS/AIMS: Patients with Ampulla of Vater cancer have a better prognosis than those with other periampullary cancers. This study aimed to determine the prognostic impact of lymph node metastasis on survival in patients with ampulla of Vater cancer after surgical resection. METHODS: From 1991 to 2016, we retrospectively reviewed data on 104 patients with ampulla of Vater cancer who had received pancreaticoduodenectomy. Clinicopathologic factors such as lymph node ratio (LNR) and number of metastatic lymph nodes that influence survival were statistically analyzed. RESULTS: 5-year survival rate after resection was 57.8%. Mean number of retrieved and metastatic lymph nodes was 13 and 0.95, respectively. In patients with lymph node metastasis, the median number of metastatic lymph nodes and was 1, and the mean LNR was 0.18. LNR ＞0.2 was a significant prognostic factor for overall survival. Patients with 0 or 1 metastatic lymph nodes had better survival than those with ≥2 metastatic lymph nodes. Univariate analysis revealed that histologic differentiation of tumor, lymph node metastasis, and T stage were significant prognostic factors for overall survival. Multivariate analysis revealed that tumor differentiation and number of metastatic lymph nodes were independent prognostic factors for survival. CONCLUSIONS: Pancreaticoduodenectomy is an appropriate surgical procedure with acceptable long-term survival for ampulla of Vater cancer. Patients with LNR ＞0.2 and ≥2 positive lymph node metastasis had a poor survival. Tumor differentiation and ≥2 metastatic lymph nodes were independent significant prognostic factors for overall survival. Curative resection with lymph node dissection might control lymph node spread and enhance survival outcomes.

Development and validation of novel scoring system for the prediction of disease recurrence following resection of colorectal liver metastasis.

BACKGROUND: The aim of this study was to identify predictive factors for the recurrence of colorectal cancer liver metastasis (CRLM) and then to develop a corresponding novel scoring system that should improve the sensitivity of predicting recurrence in patients with CRLM. METHODS: A total of 295 consecutive CRLM patients were enrolled in our institution between January 2002 and December 2015. Multivariate analyses were performed to identify the variables associated with disease recurrence and established the novel scoring system based on it. RESULTS: The scoring system considered seven variables: synchronosity, CA19-9 level, number of liver metastasis, largest size of liver metastasis, resection margin of hepatic lesion, neutrophil-to-lymphocyte ratio and prognostic nutritional index. The area under the curve of ROC was 0.824 (95% confidence interval 0.767-0.882); the sensitivity of our scoring system was 87.9%, specificity was 66.7%, positive predictive value was 20.6%, and negative predictive value was 20.9%. CONCLUSION: For patients with CRLM undergoing curative hepatic resection, our novel scoring system would improve the sensitivity for prediction of disease recurrence in Case of CRLM patients.

Prognostic markers affecting the early recurrence of hepatocellular carcinoma with liver cirrhosis after curative resection.

BACKGROUND: Early recurrence is associated with poor prognosis after curative resection for hepatocellular carcinoma. Thus, we studied which factors, including this inflammation-based scoring system, affect disease recurrence in single hepatocellular carcinoma patients with liver cirrhosis. METHODS: A total of 430 consecutive hepatocellular carcinoma patients were enrolled in our institution between January 2002 and December 2015. Survival rate, univariate, and multivariate analyses were performed to identify the variables associated with recurrence and early recurrence especially. RESULTS: The overall survival rate was significantly lower in the early recurrence group than in the non-early recurrence group (P<0.001). According to the multivariate analysis, protein induced by vitamin K absence or antagonist (PIVKA) greater than 200 (P=0.035), neutrophil-to-lymphocyte ratio greater than 2.0 (P<0.001), elevated Glasgow prognostic score (P=0.003), tumor size greater than 5 cm (P=0.002), and the presence of lymphovascular invasion (P=0.002) were significantly different among the groups and affected the early recurrence of hepatocellular carcinoma. The patients were categorized into five levels of risk for early recurrence according to the number of independent risk factors, and patients with no risk factors were set as the reference group. CONCLUSION: Neutrophil-to-lymphocyte ratio, Glasgow prognostic score, and serum level of PIVKA offer significant prognostic information associated with early recurrence following single lesion hepatocellular carcinoma patients with liver cirrhosis after curative resection.

Prognostic impact of the combination of the neutrophil-to-lymphocyte ratio and serum carbohydrate antigen 19-9 in patients with pancreas head cancer.

BACKGROUND: This study aimed to evaluate the clinical value of the combination of a traditional prognostic factor with a systemic inflammation-based prognostic factor in patients undergoing curative resection for pancreas head cancer diagnosed as pancreatic ductal adenocarcinoma. METHODS: From January 2005 to December 2015, 198 patients were enrolled. Various clinicopathological factors potentially associated with survival and recurrence were evaluated in this study. RESULTS: The selected cut-off values for the test prognostic factors with sufficient sensitivity and specificity were 2.8 for the neutrophil-to-lymphocyte ratio (NLR) and 70 U/mL for serum carbohydrate antigen 19-9 (CA19-9). Kaplan-Meier survival analysis demonstrated that the 5-year survival rate in patients with a high NLR and CA19-9 was 21.8% compared with 79.8% for patients with a low NLR and CA19-9. The 5-year disease-free survival rate in patients with a high NLR and CA19-9 was 0% compared with 33.9% for patients with a low NLR and CA19-9. Patients with high NLRs and high CA19-9 were more likely to have an early recurrence and multiple relapse patterns. CONCLUSION: Preoperative NLR and serum CA19-9 offer significant prognostic information for survival following curative resection of pancreas head cancer diagnosed as pancreatic ductal adenocarcinoma.

Laparoscopic Versus Open Liver Resection for Centrally Located Hepatocellular Carcinoma in Patients With Cirrhosis: A Propensity Score-matching Analysis.

This study aimed to compare the surgical and oncological outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for centrally located hepatocellular carcinoma in patients with cirrhosis. Between May 2013 and December 2015, 26 patients underwent pure LLR (14 underwent laparoscopic right anterior sectionectomy and 12 underwent laparoscopic central bisectionectomy). In total, 18 patients in the laparoscopic group and 36 patients in the open group were matched. When the LLR and OLR groups were compared, the operation time was found to be longer in the LLR group. However, LLR was associated with less blood loss, a shorter hospital stay, and earlier time to diet resumption. In this study, we confirmed that LLR for centrally located hepatocellular carcinoma can be safely performed in selected patients with cirrhosis despite a longer operation time.

Totally laparoscopic anatomical liver resection for centrally located tumors: A single center experience.

Laparoscopic major hepatectomy is a common procedure that has been reported frequently; however, laparoscopic resection of centrally located tumors involving segments 4, 5, and 8 remains a technically difficult procedure because it requires 2 transection planes and dissection of numerous branches of the hepatic vein and glissonean capsule compared to hemi-hepatectomy. Here, we present 7 cases of totally laparoscopic right anterior sectionectomy (Lap-RAS) and 3 cases of totally laparoscopic central bisectionectomy (Lap-CBS).Between May 2013 and January 2015, 10 totally laparoscopic anatomical resections of centrally located tumors were performed in our institution. The median age of the patients was 54.2 (38-72) years and the median ICG-R15 was 10.4 (3.9-17.4). There were 8 patients with hepatocellular carcinoma (HCC) and 2 with metastatic colorectal cancer. All the HCC patients has the liver function impairment on the degree of Child-Pugh score A.The mean operation time was 330 ±â€Š92.7 minutes with an estimated blood loss of 325 ±â€Š234.5 mL. Only 1 patient required transfusion during surgery. Mean postoperative hospital stay was 9.5 ±â€Š3.4 day and postop complication was reported only 1 case that has the fluid collection at the resection margin of the liver. Mean resection margin was 8.5 ±â€Š6.1 mm and tumor size was 2.9 ±â€Š1.9 cm.Totally lap-RAS and lap-CBS are feasible operative procedures in patients with centrally located tumor of the liver and particularly in patients with limited liver function such as those with cirrhosis.

Initial Outcomes of Pure Laparoscopic Living Donor Right Hepatectomy in an Experienced Adult Living Donor Liver Transplant Center.

BACKGROUND: Only a limited number of centers have performed laparoscopic living donor hepatectomy to date. In particular, laparoscopic right hepatectomy is rarely performed because the procedure can only be performed by surgeons with significant experience in both laparoscopic liver surgery and liver transplantation with living donor liver grafts. METHODS: Between November 2014 and February 2015, in a pure laparoscopic approach program for living right lobe donors at Asan Medical Center, 92 living donors underwent right hepatectomy for adult living donor liver transplantation. Among these, 3 pure laparoscopic living donor right hepatectomies were performed in 3 young female donors. RESULTS: The intraoperative and postoperative courses for all 3 donors and recipients were uneventful without any complications. Laparoscopic living donor hepatectomy has definite advantages over conventional open surgery, including decreased wound morbidity and faster recovery. CONCLUSIONS: According to the data of the present report, pure laparoscopic living donor right hepatectomy in properly selected living donors (only 4% of potential donors in this cohort) appears to be a safe and feasible procedure in adult living donor liver transplantation.

A Pilot Study of the Pharmacokinetics of the Modified-Release Once-Daily Tacrolimus Formulation Administered to Living-Donor Liver Transplant Recipients.

OBJECTIVES: Sustained-release once-daily tacrolimus pharmacokinetics have not yet been characterized in de novo living-donor liver transplant recipients. Here, a 12-week, phase IV, single center, open-label, prospective pilot study was conducted to investigate the pharmacokinetics of this formulation in these patients. MATERIALS AND METHODS: Patients received continuous intravenous infusion of tacrolimus on days 0 to 5 after transplant, which was followed by oral once-daily sustained-release tacrolimus. Two 24-hour pharmacokinetics profiles were generated for 10 patients on days 6 and 14. Secondary endpoints were minimum (trough level) and maximum whole blood concentrations, time to maximum concentration, and incidences of acute rejection, patient and graft survival, and adverse events. RESULTS: Mean doses (± standard deviation) of sustained-release tacrolimus on days 6 and 14 were 0.14 ± 0.03 and 0.17 ± 0.04 mg/kg. Levels were within the recommended range throughout the study. When the actual dose was examined, area under the curve from 0 to 24 hours on day 14 was 1.8-fold higher than that on day 6 (423.9 vs 235.7 ng × h/mL). When tacrolimus was normalized to 0.1 mg/kg, area under the curve from 0 to 24 hours on day 14 was 1.5-fold higher than on day 6 (279.3 vs 183.4 ng × h/mL). When we used the actual dose, we found the correlation coefficient between area under the curve from 0 to 24 hours and trough level to be higher on day 6 (r = 0.87) than on day 14 (r = 0.691). No acute rejections, graft losses, patient deaths, or drug-related adverse events were reported. CONCLUSIONS: Initial intravenous followed by sustained-release tacrolimus was safe and efficacious in living-donor liver transplant recipients. The mean area under the curve from 0 to 24 hours on day 14 was higher than previously reported; this difference may reflect cautious dosing regimens.

Preoperative prognostic values of α-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II) in patients with hepatocellular carcinoma for living donor liver transplantation.

BACKGROUND: Adult living donor liver transplantation (LDLT) is one of the best treatments for hepatocellular carcinoma (HCC). However, when recurrence of HCC after LDLT occurs, the prognosis is poor because of rapid progression. Preoperative level of α-fetoprotein (AFP) and protein induced by vitamin K antagonist-II (PIVKA-II) reportedly correlate with recurrence of HCC after LDLT. METHODS: We examined AFP and PIVKA-II preoperatively as predictors of HCC recurrence in 461 patients who underwent LDLT using right liver graft for HCC from May 2007 to December 2013. RESULTS: Among these, 77 patients (16.7%) who experienced recurrence were retrospectively reviewed. Multivariate analysis revealed tumor size >5 cm, AFP >150 nag/mol and PIVKA-II >100 maul/mol as significant independent risk factors for recurrence. The median time to recurrence was 10 months. The median survival time after recurrence was 26 months, and the 1-, 3- and 5-year survival rates after recurrence were 80.5%, 58%, and 28.3% respectively. CONCLUSIONS: Preoperatively, not only morphology of the tumor but also AFP and PIVKA-II levels can offers important information for the recurrence after LDLT for HCC. Thus, combination of tumor markers might be used for expansion of pre-existing strict selection criteria of liver transplantation for HCC.

Clinicopathological Features and Long-Term Outcomes of Intraductal Papillary Neoplasms of the Intrahepatic Bile Duct.

We intended to investigate the clinicopathological features of intrahepatic intraductal papillary neoplasms of the bile duct (IPNB), especially their malignant features and post-resection prognosis. Forty-three patients who met the definition of IPNB and who underwent liver resection between January 2002 and June 2015 were selected from our institutional database of liver resection cases. The mean age was 63.3 ± 6.9 years and 24 were male. Hepatolithiasis was present in addition in 10 of the patients. Left- and right-sided hepatectomies and concurrent bile duct resection (BDR) were performed in 28, 15, and 10 patients, respectively; R0 resection was performed in 37 patients. The mean tumor diameter was 4.1 ± 2.2 cm. Histological tumor grade was low in 4 cases, intermediate in 6, and malignant in 33. There was no cancer-related recurrence or death in the 10 patients with low-grade or intermediate lesions. In the 33 patients with malignant lesions, rates of tumor recurrence and overall survival were 12.5 and 96.2 % at 1 year, 36.4 and 91.3 % at 3 years, and 47.0 and 68.8 % at 5 years, respectively. Multivariate analysis showed that R1 resection was the only prognostic factor for tumor recurrence and patient survival. BDR was performed in only 2 of 6 patients undergoing R1 resection. Intrahepatic IPNB is a rare type of biliary neoplasm that encompasses a histological spectrum ranging from benign disease to invasive malignancy. Long-term survival was anticipated after curative resection. R1 resection reduced survival outcomes; therefore, we suggest that concurrent BDR should be performed if the resection margin of the bile duct is not reliably free of neoplastic involvement.

Effect of reoperation on long-term outcome of pT1b/T2 gallbladder carcinoma after initial laparoscopic cholecystectomy.

BACKGROUND: A small proportion of gallbladder carcinomas (GBC) are incidentally detected after laparoscopic cholecystectomy (LC). This study intended to analyze the effect of extended reoperation on the long-term outcome of patients with pT1b/T2 GBC who had initially undergone LC. METHODS: A cohort of 203 patients who underwent R0 resection and whose pathology was pT1b or pT2 GBC was divided into 3 groups: open surgery (group I, n = 150), LC only (group II, n = 25), and initial LC and subsequent reoperation (group III, n = 28). RESULTS: Mean ages were 62.3 ± 9.6 years, 65.9 ± 11.8 years, and 57.1 ± 7.7 years in groups I, II, and III, respectively (p = 0.001). The numbers of pT1b and pT2 patients were 75 and 75 in group I, 15 and 10 in group II, and 6 and 22 in group III, respectively. Residual tumors after LC were found in none of 6 pT1b patients and 5 of 22 pT2 patients. Overall 5-year patient survival rate was 70.1 % for all-cause death and 73.5 % for tumor recurrence-associated death (76.0 % in group I, 64.0 % in group II, and 63.0 % in group III [p = 0.607]; 84.4 % in pT1b group I, 68.8 % in pT1b group II, and 83.3 % in pT1b group III [p = 0.649]; 67.6 % in pT2 group I, 50 % in pT2 group II, and 61.9 % in pT2 group III [p = 0.895]). Concurrent bile duct resection in pT2 patients did not affect survival outcomes (p = 0.601). CONCLUSIONS: No definite survival benefit from reoperation was observed in patients with pT1b lesions. Residual tumor was found in 23 % of pT2 patients after reoperation, and the survival outcomes of these patients were comparable to those of the open surgery group. Therefore, reoperation for pT1b GBC following LC can be individually indicated because its indication remains unclear, but it should be highly recommended for pT2 GBC.