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.

Enhanced Photosensing and Photodynamic Treatment of Colon Cancer Cells Using Methoxy Poly(ethylene glycol)-Conjugated Chlorin e6.

Nanophotosensitizer composed of methoxy poly(ethylene glycol) (MePEG) and chlorin e6 (Ce6) (abbreviated as Pe6) was synthesized for efficient delivery of Ce6 to the colon cancer cells. Pe6 nanophotosensitizer has small diameter less than 100 nm with spherical shape and core-shell structure. They were activated in aqueous solution while Ce6 was quenched due to its poor aqueous solubility. They showed no intrinsic cytotoxicity against normal cells and colon cancer cells. Pe6 nanophotosensitizers showed enhanced cellular uptake, phototoxicity, and reactive oxygen species (ROS) generation at in vitro cell culture experiment. Furthermore, they showed improved tumor tissue penetration and accumulation in vivo animal studies. We suggested Pe6 nanophotosensitizers as an ideal candidate for PDT of colon cancer.

Donor safety in living donor liver transplantation: The Korean organ transplantation registry study.

Major concerns about donor safety cause controversy and limit the use of living donor liver transplantation to overcome organ shortages. The Korean Organ Transplantation Registry established a nationwide organ transplantation registration system in 2014. We reviewed the prospectively collected data of all 832 living liver donors who underwent procedures between April 2014 and December 2015. We allocated the donors to a left lobe group (n = 59) and a right lobe group (n = 773) and analyzed the relations between graft types and remaining liver volumes and complications (graded using the Clavien 5-tier grading system). The median follow-up was 19 months (range, 10-31 months). During the study period, 553 men and 279 women donated livers, and there were no deaths after living liver donation. The overall, biliary, and major complication (grade ≥ III) rates were 9.3%, 1.7%, and 1.9%, respectively. The graft types and remaining liver volume were associated with significantly different overall, biliary, and major complication rates. Of the 16 patients with major complications, 9 (56.3%) involved biliary complications (2 biliary strictures [12.5%] and 7 bile leakages [43.8%]). Among the 832 donors, the mean aspartate transaminase, alanine aminotransferase, and total bilirubin levels were 23.9 ± 8.1 IU/L, 20.9 ± 11.3 IU/L, and 0.8 ± 0.4 mg/dL, respectively, 6 months after liver donation. In conclusion, biliary complications were the most common types of major morbidity in living liver donors. Donor hepatectomy can be performed successfully with minimal and easily controlled complications. Our study shows that prospective, nationwide cohort data provide an important means of investigating the safety in living liver donation. Liver Transplantation 23 999-1006 2017 AASLD.

Risk factors of early recurrence after curative hepatectomy in hepatocellular carcinoma.

Early recurrence is common after curative hepatectomy for hepatocellular carcinoma and is associated with poor prognosis. This study aimed to identify risk factors of early recurrence after curative hepatectomy in hepatocellular carcinoma. Overall, 63 patients who underwent curative hepatectomy for hepatocellular carcinoma were enrolled. Patients were divided into the early recurrence group, who developed recurrence within 12 months after hepatectomy (n = 10), and the non-early recurrence group (n = 53). Clinicopathological factors of early recurrence were retrospectively analyzed. Among the 63 patients, 10 (15.9%) patients experienced early recurrence. Univariate analysis showed tumor necrosis (p = 0.012), level of PIVKA-II (prothrombin induced by vitamin K absence or antagonist-II; p = 0.002), and microvascular invasion (p = 0.029) to be associated with early recurrence. By multivariate analysis, there were significant differences in high PIVKA-II (p < 0.001) and tumor necrosis (p = 0.012) in patients with early recurrence. The optimal cutoff values of PIVKA-II and tumor necrosis were 46 mAU/mL and 3% of total tumor volume, respectively. Patients with a high preoperative PIVKA-II level and extent of tumor necrosis, which are independent risk factors for early recurrence, should be actively treated and monitored closely after hepatectomy.

Increasing use of therapeutic apheresis as a liver-saving modality.

INTRODUCTION: Therapeutic plasma exchange (TPE) is used for temporary support of liver function in patients presenting with early graft dysfunction after liver transplantation (LT) or liver surgery. We analyzed the effect of therapeutic apheresis on patients with liver disease. METHODS: Between January 2011 and August 2016, 93 apheresis procedures were performed for 26 patients at our institution. Anti-ABO isoagglutination immunoglobulin (Ig) M titer was checked using a type A and type B 3% red blood cell (RBC) suspension in saline with two-fold serial dilutions of patient serum. Anti-ABO isoagglutination IgG titer was checked by a type A and B 0.8% RBC suspension using a low-ionic strength/Coombs card. RESULTS: ABO-incompatible (ABOi) LT was the most common (n=10, 38.5%) indication for apheresis; early graft dysfunction after LT (n=8, 30.7%) was the second most common. Median initial IgM and IgG anti-ABO titers for ABOi LT recipients were 1:16 (range, 1:8-1:128) and 1:48 (range, 1:8-1:2048). We performed preoperative TPE in 10 recipients (median number of sessions, 1.5; range, 1-11). Among patients with early graft dysfunction, those who underwent living donor LT had better survival (4/4; 100%) than those who underwent nonliving donor LT (0/3; 0%). Patients who underwent living donor LT first and then additional LT also survived after three TPE sessions. CONCLUSION: Therapeutic apheresis is associated with a good survival rate and is essential for liver support in patients with early graft dysfunction after LT or posthepatectomy liver failure and during preparation for ABOi LT.

Efficacy and patency of primary stenting for hepatic venous outflow obstruction after living donor liver transplantation.

BACKGROUND: Hepatic venous outflow is important for graft survival in living donor liver transplantation (LDLT). If hepatic venous outflow obstruction occurs, hepatic vein stenting is considered to restore the patency. PURPOSE: To retrospectively evaluate the efficacy and patency of primary hepatic vein stenting for hepatic venous outflow obstruction (HVOO) after LDLT. MATERIAL AND METHODS: Percutaneous interventions, including hepatic vein stent placement with or without balloon angioplasty, were performed in 21 patients who had undergone LDLT and had HVOO confirmed through hepatic venography or manometry, including the patients who had a structural abnormality. Two stents each were inserted in four patients; therefore, the total number of treated anastomoses was 25. Technical success, patency rates, and pressure gradients between hepatic veins and the right atrium were evaluated in 19 patients each. RESULTS: Technical success was achieved in 25 of 26 vessels (96%). The mean interval between operation and stenting was 43 days. After the procedure, the follow-up period was a mean 530 days. The mean pressure gradient decreased from 8.5 mmHg to 2.1 mmHg after treatment (P < 0.01). The patency rates of the 25 vessels were 80% at 1, 2, and 3 years after stent placement. However, middle hepatic vein stenting revealed a low patency rate (all were 36%). Three of seven stents (43%) in the middle hepatic vein occluded during follow-up. CONCLUSION: Percutaneous primary hepatic vein stent replacement is an effective treatment for HVOO after LDLT.

Clinical Impacts of Donor Types of Living vs. Deceased Donors: Predictors of One-Year Mortality in Patients with Liver Transplantation.

Transplantation studies about the clinical differences according to the type of donors are mostly conducted in western countries with rare reports from Asians. The aims of this study were to evaluate the clinical impacts of the type of donor, and the predictors of 1-year mortality in patients who underwent liver transplantation (LT). This study was performed for liver transplant recipients between May 2010 and December 2014 at the Pusan National University Yangsan Hospital. A total of 185 recipients who underwent LT were analyzed. Of the 185 recipients, 109 (58.9%) belonged to the living donor liver transplantation (LDLT) group. The median age was 52.4 years. LDLT recipients had lower model for end-stage liver disease (MELD) score compared with better liver function than deceased donor liver transplantation (DDLT) recipients (mean ± standard deviation [SD], 12.5 ± 8.3 vs. 24.9 ± 11.7, respectively; P < 0.001), and had more advanced hepatocellular carcinoma (HCC) (62.4% vs. 21.1%, respectively; P = 0.001). In complications and clinical outcomes, LDLT recipients showed shorter stay in intensive care unit (ICU) (mean ± SD, 10.8 ± 8.8 vs. 23.0 ± 13.8 days, respectively, P < 0.001), ventilator care days, and post-operative admission days, and lower 1-year mortality (11% vs. 27.6%, respectively, P = 0.004). Bleeding and infectious complications were less in LDLT recipients. Recipients with DDLT (P = 0.004) showed higher mortality in univariate analysis, and multi-logistic regression analysis found higher MELD score and higher pre-operative serum brain natriuretic peptide (BNP) were associated with 1-year mortality. This study may guide improved management before and after LT from donor selection to post-operation follow up.

Self-assembled polymeric micelles based on hyaluronic acid-g-poly(D,L-lactide-co-glycolide) copolymer for tumor targeting.

Graft copolymer composed hyaluronic acid (HA) and poly(D,L-lactide-co-glycolide) (PLGA) (HAgLG) was synthesized for antitumor targeting via CD44 receptor of tumor cells. The carboxylic end of PLGA was conjugated with hexamethylenediamine (HMDA) to have amine end group in the end of chain (PLGA-amine). PLGA-amine was coupled with carboxylic acid of HA. Self-assembled polymeric micelles of HAgLG have spherical morphologies and their sizes were around 50-200 nm. Doxorubicin (DOX)-incorporated polymeric micelles were prepared by dialysis procedure. DOX was released over 4 days and its release rate was accelerated by the tumoric enzyme hyaluronidase. To assess targetability of polymeric micelles, CD44-positive HepG2 cells were employed treated with fluorescein isothiocyanate (FITC)-labeled polymeric micelles. HepG2 cells strongly expressed green fluorescence at the cell membrane and cytosol. However, internalization of polymeric micelles were significantly decreased when free HA was pretreated to block the CD44 receptor. Furthermore, the CD44-specific anticancer activity of HAgLG polymeric micelles was confirmed using CD44-negative CT26 cells and CD44-positive HepG2 cells. These results indicated that polymeric micelles of HaLG polymeric micelles have targetability against CD44 receptor of tumor cells. We suggest HAgLG polymeric micelles as a promising candidate for specific drug targeting.

Regular exercise training increases the number of endothelial progenitor cells and decreases homocysteine levels in healthy peripheral blood.

Endothelial progenitor cells (EPCs) are known to play an important role in the repair of damaged blood vessels. We used an endothelial progenitor cell colony-forming assay (EPC-CFA) to determine whether EPC numbers could be increased in healthy individuals through regular exercise training. The number of functional EPCs obtained from human peripheral blood-derived AC133 stem cells was measured after a 28-day regular exercise training program. The number of total endothelial progenitor cell colony-forming units (EPC-CFU) was significantly increased compared to that in the control group (p=0.02, n=5). In addition, we observed a significant decrease in homocysteine levels followed by an increase in the number of EPC-CFUs (p=0.04, n=5), indicating that the 28-day regular exercise training could increase the number of EPC colonies and decrease homocysteine levels. Moreover, an inverse correlation was observed between small-endothelial progenitor cell colony-forming units (small-EPC-CFUs) and plasma homocysteine levels in healthy men (r=-0.8125, p=0.047). We found that regular exercise training could increase the number of EPC-CFUs and decrease homocysteine levels, thus decreasing the cardiovascular disease risk in men.

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.

Metallic or plastic stent for bile duct obstruction in ampullary cancer?

BACKGROUND AND AIMS: Although ampullary cancer is a relatively uncommon malignancy, it is frequently associated with biliary obstruction. Endoscopic biliary drainage is regarded as a palliative treatment of choice for patients with inoperable ampullary cancer. However, there are no data concerning choice of stent in this patient population. The objective of this study was to compare the efficacy of metallic and plastic stents for biliary obstruction in patients with ampullary cancer. METHODS: Thirty-seven patients (15 men and 22 women; median age 74.7 years) with ampullary cancer treated with endoscopic biliary drainage were enrolled. Metallic and two plastic stents were placed in 17 and 20 patients, respectively. Clinical success, stent patency, and stent malfunction were evaluated. RESULTS: Clinical success was achieved in all patients (100%). The median period of stent patency was 132.7 days in the metallic stent group and 128.5 days in the plastic stent group (P > 0.05). Stent malfunctions developed in 17 and 19 patients in the metallic and plastic stent groups, respectively. Stent occlusion occurred in 15 (88.2%) and 15 (75%) patients and stent migration occurred in two (11.8%) and four (20%) patients in the metallic and plastic stent groups, respectively. CONCLUSIONS: Endoscopic biliary drainage using metallic or plastic stents is effective for initial endoscopic palliation in patients with obstructive jaundice because of ampullary cancer. Although metallic and plastic stents had similar clinical effect, it seems reasonable to choose two plastic stents as the first option in patients with ampullary cancer considering the cost-effectiveness.

Current status of laparoscopic liver resection in Korea.

Since laparoscopic liver resection was first introduced in 2001, Korean surgeons have chosen a laparoscopic procedure as one of the treatment options for benign or malignant liver disease. We distributed and analyzed a nationwide questionnaire to members of the Korean Laparoscopic Liver Surgery Study Group (KLLSG) in order to evaluate the current status of laparoscopic liver resection in Korea. Questionnaires were sent to 24 centers of KLLSG. The questionnaire consisted of operative procedure, histological diagnosis of liver lesions, indications for resection, causes of conversion to open surgery, and postoperative outcomes. A laparoscopic liver resection was performed in 416 patients from 2001 to 2008. Of 416 patients, 59.6% had malignant tumors, and 40.4% had benign diseases. A total laparoscopic approach was performed in 88.7%. Anatomical laparoscopic liver resection was more commonly performed than non-anatomical resection (59.9% vs 40.1%). The anatomical laparoscopic liver resection procedures consisted of a left lateral sectionectomy (29.3%), left hemihepatectomy (19.2%), right hemihepatectomy (6%), right posterior sectionectomy (4.3%), central bisectionectomy (0.5%), and caudate lobectomy (0.5%). Laparoscopy-related serious complications occurred in 12 (2.8%) patients. The present study findings provide data in terms of indication, type and method of liver resection, and current status of laparoscopic liver resection in Korea.

Effect of CYP3A5 on the Once-Daily Tacrolimus Conversion in Stable Liver Transplant Patients.

Cytochrome P450 (CYP) 3A5 polymorphism influences tacrolimus metabolism, but its effect on the drug pharmacokinetics in liver transplant recipients switched to once-daily extended-release formulation remains unknown. The aim of this study is to analyze the effect of CYP3A5 polymorphism on liver function after once-daily tacrolimus conversion in liver transplant patients. A prospective open-label study included 60 stable liver transplant recipients who underwent 1:1 conversion from twice-daily tacrolimus to once-daily tacrolimus. All participants were genotyped for CYP3A5 polymorphism. The study was registered at ClinicalTrials.gov (NCT02882113). Twenty-eight patients were enrolled in the CYP3A5 expressor group and 32 in the non-expressor group. Although there was no statistical difference, incidence of liver dysfunction was higher in the expressor group than in the non-expressor group when converted to once-daily extended-release tacrolimus (p = 0.088). No biopsy-proven acute rejection, graft failure, and mortality were observed in either group. The decrease in dose-adjusted trough level (-42.9% vs. -26.1%) and dose/kg-adjusted trough level of tacrolimus (-40.0% vs. -23.7%) was significantly greater in the expressor group than in the non-expressors after the conversion. A pharmacokinetic analysis was performed in 10 patients and tacrolimus absorption in the non-expressor group was slower than in the expressor group. In line with this observation, the area under the curve for once-daily tacrolimus correlated with trough level (Cmin) in the non-expressors and peak concentration (Cmax) in the expressors. CYP3A5 genotyping in liver transplant recipients leads to prediction of pharmacokinetics after switching from a twice-daily regimen to a once-daily dosage form, which makes it possible to establish an appropriate dose of tacrolimus.

A Randomized Phase II Study of Perioperative Chemotherapy Plus Bevacizumab Versus Postoperative Chemotherapy Plus Bevacizumab in Patients With Upfront Resectable Hepatic Colorectal Metastases.

INTRODUCTION: Whether patients with resectable colorectal liver metastases (CRLM) gain a survival benefit from perioperative chemotherapy remains controversial. The benefit of including bevacizumab in chemotherapy also remains unclear. MATERIAL AND METHODS: Seventy-six patients with CRLM were randomly assigned to either 6 cycles of FOLFOX (folinic acid, 5-fluorouracil, and oxaliplatin)/FOLFIRI (folinic acid, 5-fluorouracil, and irinotecan) with bevacizumab before and after surgery or 12 cycles after surgery. Progression-free survival (PFS) was estimated using the Kaplan-Meier method and compared by the log-rank test. RESULTS: The median PFS of all patients was 37.4 months at 5.4 years follow-up, and the median overall survival (OS) was not reached. The PFS between the perioperative group and the postoperative group did not reveal a statistical difference (P = .280). The OS was significantly better in the perioperative group (hazard ratio [HR], 0.60; 95% confidence interval [CI],) 0.35-1.02; P = .049). In subgroup patients with carcinoembryonic antigens (CEA) ≥ 5 ng/mL or those with over 2 liver metastases, perioperative group had longer OS than postoperative group (CEA: HR, 0.49; 95% CI, 0.25-0.93; P = .030; number of liver metastases: HR, 0.55; 95% CI, 0.30-0.99; P = .049). The largest liver metastases size, disease-free interval, and sidedness did not affect PFS or OS. There was no difference between the 2 groups in postoperative complications with bevacizumab or adverse events during chemotherapy. CONCLUSIONS: In patients with resectable CRLMs, perioperative chemotherapy had no effect on PFS, but improved OS. Patients with high CEA levels or over 2 liver metastases may benefit from perioperative chemotherapy.

Modified right lobe graft with bovine pericardium for middle hepatic vein reconstruction.

Modified right lobe graft with middle hepatic vein reconstruction is commonly carried out in living donor liver transplantation these days. Cadaveric vascular graft has been widely used to maintain good outflow in middle hepatic vein tributaries. However, cadaveric donors are limited in Korea. This problem may be compensated with bovine pericardium. From April 2007, we experienced 4 cases of modified right lobe graft living donor liver transplantation using bovine pericardium. After donor hepatectomy, a 2-cm diameter cylinderic shape was made with the large sized bovine pericardium. V5 and V8 (greater than 5mm in diameter) were anastomosed to the bovine pericardium with end-to-side pattern. After reperfusion, it was anastomosed to the recipient's middle and left hepatic vein trunk. All patients recovered well and are currently remaining good liver function (3 to 11 months). Three cases maintain tolerable middle hepatic venous flow and have no congestion of right anterior sector in enhanced computerized tomography or in Doppler ultrasonography. Bovine pericardium can be one of the alternative materials for middle hepatic vein reconstruction of modified right lobe graft in the area of cadaveric organ shortage.

Ante-situm liver resection in recurrent liver metastasis from colorectal cancer.

Surgical resection of liver metastases from colorectal cancer can offer long-term survival and cure in patients with metastatic colorectal cancer isolated to the liver. We present a case of a recurrent liver metastasis from rectal cancer, managed with ante-situm liver resection under total vascular exclusion and venovenous bypass with hypothermic perfusion. A 58-year-old man, who was diagnosed with liver metastasis from rectal cancer underwent a left lateral sectionectomy in January 2006. A recurrent lesion developed 1 year after the first hepatectomy. The tumor was 5 cm in size, locating at segments I, IV, and VIII. It was involved in the origin of middle hepatic vein and retro-hepatic vena cava. We performed ante-situm liver resection under total vascular exclusion and venovenous bypass with hypothermic perfusion. The patient remains well without recurrence for 12 months after the last operation. Ante-situm technique made it easy to approach and completely removes the recurrent lesion locating at hardly accessible site and having the incomplete removal risk by conventional liver resection. The authors also reconfirmed that repeat hepatectomy is valuable in recurrent colorectal liver metastases.

Diamond-shaped patch technique for right hepatic vein reconstruction in living-donor liver transplant: A simple method to prevent stenosis.

Patency of the right hepatic vein (RHV) of the liver graft is essential for successful living-donor liver transplant (LDLT). We developed a simple technique for RHV reconstruction that does not require the use of cadaveric veins or additional time to prevent stenosis.Of 159 patients who underwent LDLT at our institution between May 2010 and April 2016, we included 152 in this study. Conventional RHV reconstruction was performed in 100 patients, while the diamond-shaped patch (D-patch) technique was performed in 53. For the D-patch technique, the posterior aspect of the RHV needs to be dissected from the liver parenchyma during donor hepatectomy, which prevents stenosis due to liver rotation after graft regeneration. A D-patch obtained from the hepatic vein of the recipient liver was used on the anterior aspect of the RHV for reconstruction. The Student's t test and χ test were used for statistical analysis.Rates of intervention for RHV stenosis during the first month were significantly different between the conventional reconstruction and D-patch groups (19.2% vs 3.8%; P = .01). The time taken to perform the D-patch technique was similar to that for conventional reconstruction (anhepatic period, 104.9 ±â€Š47.3 minutes vs 106.7 ±â€Š42.0 minutes; P = .82).The D-patch technique for RHV reconstruction in LDLT is a simple, fast, and feasible surgical technique that can be performed without using cadaveric or saphenous veins.

Predictors of postoperative infectious complications in liver transplant recipients: experience of 185 consecutive cases.

Background/Aims: Infections following liver transplant (LT) remain a major cause of mortality. This study was conducted to evaluate risk factors for infection and to review clinical characteristics. METHODS: Medical records of patients who underwent LT from 2010 to 2014 were retrospectively analyzed. Binary logistic regression analysis was used to investigate risk factors of infection. Kaplan-Meier analysis was used to predict prognosis of infected and non-infected groups. RESULTS: Of 185 recipients, 89 patients experienced infectious complications. The median follow-up period was 911 days (range, 9 to 2,031). The infected group had higher 1-year mortality (n = 22 [24.7%] vs. n = 8, [8.3%], p = 0.002), and longer postoperative admission days (mean: 53.7 ± 35.8 days vs. 28.3 ± 13.0 days, p < 0.001), compared to the non-infected group. High preoperative Model for End-Stage Liver Disease (MELD) score (odds ratio [OR], 1.057; 95% confidence interval [CI], 1.010 to 1.105; p = 0.016), deceased-donor type (OR, 5.475; 95% CI, 2.442 to 12.279; p < 0.001), and acute rejection (OR, 3.042; 95% CI, 1.241 to 7.454; p = 0.015) were independent risk factors associated with infection. Intra-abdominal infection (n = 35, 20.8%) was the major infectious complication. Among identified bacteria, Enterococcus species (28.4%) were major pathogens, followed by Escherichia coli and Klebsiella species. Conclusions: High preoperative MELD score, deceased-donor type, and acute rejection were risk factors associated with infection. To prevent infections following surgery, it is important to determine the appropriate time of operation before the recipient has a high MELD score.

Pancreas Transplant with Duodeno-Duodenostomy and Caval Drainage Using a Diamond Patch Graft: A Single-Center Experience.

BACKGROUND The surgical technique used in pancreas transplant is essential for patient safety and graft survival, and problems exist with conventional strategies. When enteric exocrine drainage is performed, there is no method of immunologic monitoring other than direct graft pancreas biopsy. The most common cause of early graft failure is graft thrombosis, and adequate preventive and treatment strategies are unclear. To overcome these disadvantages, we suggest a modified surgical technique. MATERIAL AND METHODS Eleven patients underwent pancreas transplant with our modified technique. The modified surgical techniques are as follows: 1) graft duodenum was anastomosed with recipient duodenum to enable endoscopic immunological monitoring, and 2) the inferior vena cava was chosen for vascular anastomosis and a diamond-shaped patch was applied to prevent graft thrombosis. RESULTS No patient mortality or graft failure occurred. One case of partial thrombosis of the graft portal vein occurred, which did not affect graft condition, and resolved after heparin treatment. All patients were cured from diabetes mellitus. There were no cases of pancreatic rejection, but 2 cases of graft duodenal rejection occurred, which were adequately treated with steroid therapy. CONCLUSIONS This modified surgical technique for pancreas transplant represents a feasible method for preventing thrombosis and allows for direct graft monitoring through endoscopy.