Publications by authors named "Gyu-Seong Choi"

126 Publications

Cost-effectiveness and long-term outcomes of liver transplantation using anti-HBc-positive grafts with hepatitis B immunoglobulin prophylaxis in Korea.

Clin Mol Hepatol 2021 Sep 8. Epub 2021 Sep 8.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background: Hepatitis B core antibody (anti-HBc) positive donors are used as an extended donor pool, and current guidelines recommend the usage of nucleos(t)ide analogues (NAs) as prophylaxis for preventing de novo hepatitis B virus infection (DNH). In this study, we analyzed the long-term outcomes of a large cohort of liver transplantation (LT) patients receiving anti-HBc-positive grafts and evaluated the risks of DNH when HBIG monotherapy was used as prophylaxis. Also, we compared the cost-effectiveness of HBIG and NAs.

Methods: We retrospectively reviewed 457 patients with anti-HBc-positive grafts and 898 patients with anti-HBc-negative grafts who underwent LT between January 2001 and December 2018. The comparison of recipient characteristics according to the anti-HBc status of the donor was done. Also, the cost was compared between using NAs for the rest of one's life and using HBIG to maintain hepatitis B surface antibody titers above 200 IU/L.

Results: The 1-, 5-, and 10-year patient survival rates were 87.7%, 73.5%, and 67.7%, respectively in patients with anti-HBc-positive grafts and 88.5%, 77.4%, and 70.3%, respectively in patients with anti-HBc-negative grafts (P = 0.113). Among 457 recipients with anti-HBc-positive grafts, 117 (25.6%, 117/457) were non-HBV recipients. The overall incidence of DNH was 0.9% (1/117). When using HBIG, the cumulative cost was lower compared with using NA continuously in Korea.

Conclusions: The anti-HBc-positive graft itself does not affect patient survival or graft survival. HBIG monoprophylaxis has good outcomes for preventing DNH, and the patient's long-term cost burden can be low in Korea considering the insurance system in this cohort.
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http://dx.doi.org/10.3350/cmh.2021.0137DOI Listing
September 2021

Bilateral continuous erector spinae plane block using a programmed intermittent bolus regimen versus intrathecal morphine for postoperative analgesia in living donor laparoscopic hepatectomy: A randomized controlled trial.

J Clin Anesth 2021 Aug 26;75:110479. Epub 2021 Aug 26.

Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. Electronic address:

Study Objective: To determine if continuous bilateral erector spinae plane (ESP) blocks would improve the postoperative analgesia in the first 48 h after laparoscopic donor hepatectomy, compared to intrathecal morphine (ITM).

Design: Prospective, randomized controlled trial.

Setting: A single tertiary care center from October 2019 and September 2020.

Patients: A total of 60 donors scheduled to undergo elective laparoscopic right hepatectomy.

Interventions: Sixty donors were randomized to receive either bilateral continuous T8 ESP blocks with a programmed intermittent bolus regimen of 10 mL 0.2% ropivacaine every 3 h for 48 h (n = 30) or 400 μg ITM (n = 30), in addition to IV fentanyl PCA and multimodal analgesia.

Measurements: The primary outcome was cumulative opioid consumption over the first 48 h, expressed as IV morphine equivalents. Secondary outcomes included pain scores, Quality of Recovery-15 scores, ambulation within 24 h, time to first flatus, and opioid-related adverse drug events over 72 h.

Main Results: Fifty-nine donors were analyzed. Cumulative 48-h opioid consumption was similar between the ITM and ESP groups (29.8 ± 18.2 vs. 35.1 ± 21.9 mg, mean difference (ESP-ITM) (95% CI), 5.3 (-11.5 to 22) mg; p > 0.99). Resting pain scores at 48 and 72 h postoperatively were significantly lower in the ESP group (0 [0-2] vs. 3 [1.5-3], and 0 [0-2] vs. 3 [1-3] respectively, both p<0.001) (Goldaracena and Barbas, 2019; Ko et al., 2009; Choi et al., 2007 [1-3]) respectively, both p < 0.001). The ESP group had significantly lower incidences of postoperative nausea, vomiting, and pruritus at all timepoints. There were no differences in recovery outcomes.

Conclusions: Continuous ESP blocks did not reduce cumulative 48-h opioid consumption compared to 400 μg ITM after laparoscopic donor hepatectomy, but it was associated with a significantly reduced risk of postoperative nausea, vomiting and pruritus.

Clinical Trial Number And Registry Url: Clinical Trial Registry of Korea; https://cris.nih.go.kr/cris/index.jsp and identifier: KCT0004313; date of registration: October 15, 2019; principal investigator's name: Justin Sangwook Ko.
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http://dx.doi.org/10.1016/j.jclinane.2021.110479DOI Listing
August 2021

A modified LI-RADS: targetoid tumors with enhancing capsule can be diagnosed as HCC instead of LR-M lesions.

Eur Radiol 2021 Aug 4. Epub 2021 Aug 4.

Department of Mathematics, Ajou University, Suwon, Republic of Korea.

Objective: To elucidate whether the presence of enhancing capsule can be applied to establish a modified Liver Imaging Reporting and Data System (LI-RADS) to differentiate hepatocellular carcinoma (HCC) from non-HCC malignancies in extracellular contrast agent (ECA)-enhanced and hepatobiliary agent (HBA)-enhanced MRI.

Methods: We enrolled 198 participants (161 men; mean age, 56.3 years) with chronic liver disease who underwent ECA-MRI and HBA-MRI before surgery for de novo hepatic nodule(s). Two reviewers assigned LI-RADS categories (v2018). We defined a "modified LR-5 category, which emphasizes enhancing capsule (mLR-5C)" over targetoid features and classifies tumors with both targetoid appearance and enhancing capsule as HCC instead of LR-M. We compared the diagnostic performance of conventional LI-RADS and modified LI-RADS criteria for both MRIs.

Results: A total of 258 hepatic nodules (194 HCCs, 43 benign lesions, and 21 non-HCC malignancies; median size, 19 mm) were analyzed. By conventional LI-RADS, 47 (18.2%) nodules (31 HCCs and 16 non-HCC malignancies) were categorized as LR-M. The mLR-5C criterion showed superior sensitivity (ECA-MRI, 76.6% vs. 67.0%; HBA-MRI, 60.4% vs. 56.3%; both p < 0.05) while maintaining high specificity (ECA-MRI, 93.8% vs. 98.4%; HBA-MRI, 95.3% vs. 98.4%; both p > 0.05) compared with the LR-5 criterion. Using the mLR-5C criterion, ECA-MRI exhibited higher sensitivity than HBA-MRI (76.6% vs. 60.4%, p < 0.001) and similar specificity (93.8% vs. 95.3%, p > 0.99).

Conclusion: Our modified LI-RADS achieved superior sensitivity for diagnosing HCC, without compromising specificity compared with LR-5. ECA-MRI showed higher sensitivity in diagnosing HCC than HBA-MRI by applying the mLR-5C for LR-M lesions.

Key Points: • By conventional LI-RADS, 31 (16.0%) of 194 HCCs were categorized as LR-M. • Among 31 HCCs categorized as LR-M, 19 HCCs or 8 HCCs were recategorized as HCC on ECA-MRI or HBA-MRI, respectively, after applying the modified LR-5 category, which allocates targetoid lesions with enhancing capsule as mLR-5C instead of LR-M. • The mLR-5C showed superior sensitivity compared with the LR-5 in both MRIs (ECA-MRI, 76.6% vs. 67.0%; HBA-MRI, 60.4% vs. 56.3%, both p < 0.05), while maintaining high specificity (ECA-MRI, 93.8% vs. 98.4%; HBA-MRI, 95.3% vs. 98.4%; both p > 0.05).
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http://dx.doi.org/10.1007/s00330-021-08124-0DOI Listing
August 2021

Surgical Techniques and Outcomes of Pure Laparoscopic Donor Right Posterior Sectionectomy for Living Donor Liver Transplantation.

Liver Transpl 2021 Jul 27. Epub 2021 Jul 27.

Department of Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University School of Medicine, Seoul, Korea.

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http://dx.doi.org/10.1002/lt.26244DOI Listing
July 2021

EASL versus LI-RADS: Intra-individual comparison of MRI with extracellular contrast and gadoxetic acid for diagnosis of small HCC.

Liver Int 2021 Jul 9. Epub 2021 Jul 9.

Department of Mathematics, Ajou University, Suwon, Republic of Korea.

Background & Aims: Liver Imaging Reporting and Data System (LI-RADS) and European Association for the Study (EASL) criteria for hepatocellular carcinoma (HCC) diagnosis have been updated in 2018. We aimed to compare the HCC diagnostic performance of LI-RADS and EASL criteria with extracellular contrast agents-MRI (ECA-MRI) and hepatobiliary agents-MRI (HBA-MRI).

Methods: We prospectively evaluated 179 participants with cirrhosis (n = 105) or non-cirrhotic chronic hepatitis B (CHB) (n = 74) who underwent both ECA-MRI and HBA-MRI before surgery for de novo nodule(s) measuring 10-30 mm. We compared the HCC diagnostic performance of EASL and LR-5 in both MRIs.

Results: In an analysis of 215 observations (175 HCCs, 17 non-HCC malignancies and 23 benign lesions) identified from cirrhotic or non-cirrhotic CHB participants, LR-5 with ECA-MRI provided the highest sensitivity (80.7%), followed by EASL with ECA-MRI (76.2%), LR-5 with HBA-MRI (67.3%) and EASL with HBA-MRI (63.0%, all P < .05). The specificities were comparable (89.4%-91.5%). When the analysis is limited to participants with pathological cirrhosis (123 observations), the sensitivity of LR-5 with ECA-MRI was similar to that of EASL with ECA-MRI (82.7% vs 80.2%, P = .156), but higher than LR-5 with HBA-MRI (65.1%) or EASL with HBA-MRI (62.8%, both P < .001), with comparable specificities (87.5%-91.7%).

Conclusions: The LR-5 with ECA-MRI yielded the highest sensitivity with a similar specificity for HCC diagnosis in cirrhosis and non-cirrhotic CHB participants, while the sensitivities of LR-5 and EASL with ECA-MRI are similar for cirrhosis participants. This indicates non-invasive diagnosis criteria can differ by contrast agents and presence of cirrhosis.
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http://dx.doi.org/10.1111/liv.15012DOI Listing
July 2021

Risk factors for poor survival after recurrence of hepatocellular carcinoma after liver transplantation.

Ann Surg Treat Res 2021 Jul 30;101(1):28-36. Epub 2021 Jun 30.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Purpose: This study was designed to analyze the risk factors for poor survival after recurrence of hepatocellular carcinoma after liver transplantation.

Methods: Patients who underwent liver transplantation for hepatocellular carcinoma during the period of 2007 to 2018 were reviewed and patients who experienced recurrence were included. Multivariable Cox proportional hazard ratios were performed for potential risk factors for survival after recurrence.

Results: A total of 151 recipients experienced hepatocellular carcinoma recurrence after liver transplantation. The median of the recurrence-free period was 9.3 months (0.89-97.25 months). The median follow-up after recurrence was 13.4 months (0.59-118.28 months). One-, 3-, and 5-year survival after recurrence were 65.2%, 34.0% and 20.5%, respectively. Multivariable Cox analysis showed that, graft from living donor (hazard ratio [HR], 0.430; 95% confidence interval [CI], 0.210-0.882; P = 0.021), recurrence-free interval of ≥9 months (HR, 0.257; 95% CI, 0.164-0.403; P < 0.001), alphafetoprotein of ≥100 ng/mL at the time of recurrence (HR, 1.689; 95% CI, 1.059-2.695; P = 0.028), and recurrence in bone (HR, 2.304; 95% CI, 1.399-3.794; P = 0.001) and everolimus within 3 months after recurrence (HR, 0.354; 95% CI, 0.141-0.889; P = 0.027) were related to survival after recurrence.

Conclusion: Although survival was generally poor after recurrence of hepatocellular carcinoma in liver transplantation recipients, prolonged survival can be achieved in certain patients with better prognostic factors.
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http://dx.doi.org/10.4174/astr.2021.101.1.28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8255579PMC
July 2021

Liver transplantation of a patient with extreme thrombocytopenia - A case report.

Anesth Pain Med (Seoul) 2021 Jul 5;16(3):279-283. Epub 2021 Jul 5.

Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: Patients with chronic liver disease (CLD) planned for liver transplantation (LT) often show severe thrombocytopenia, but there is a lack of evidence in deciding the threshold for prophylactic platelet transfusion.

Case: A 47-year-old female with acute liver failure was referred for LT. Despite daily transfusion of platelets, platelet counts remained under 10,000/µl. During LT, 2 units of single donor platelets (SDP) were transfused. Although platelet counts remained extremely low (3,000-4,000/µl) no diffuse oozing was observed and the blood loss was 860 ml. Postoperatively, there was no sign of active bleeding or oozing, and the patient received only 1 unit SDP transfusion.

Conclusions: CLD patients may have severe thrombocytopenia. However, primary hemostasis may not be significantly hindered due to the existence of rebalanced hemostasis. Prophylactic platelet transfusion in these patients should not be decided based on platelet counts only, but also take other coagulation tests and clinical signs into consideration.
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http://dx.doi.org/10.17085/apm.21006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8342821PMC
July 2021

Tailored Prediction Model of Survival after Liver Transplantation for Hepatocellular Carcinoma.

J Clin Med 2021 Jun 28;10(13). Epub 2021 Jun 28.

Department of Surgery, Seoul National University College of Medicine, Seoul 03080, Korea.

This study aimed to create a tailored prediction model of hepatocellular carcinoma (HCC)-specific survival after transplantation based on pre-transplant parameters. Data collected from June 2006 to July 2018 were used as a derivation dataset and analyzed to create an HCC-specific survival prediction model by combining significant risk factors. Separate data were collected from January 2014 to June 2018 for validation. The prediction model was validated internally and externally. The data were divided into three groups based on risk scores derived from the hazard ratio. A combination of patient demographic, laboratory, radiological data, and tumor-specific characteristics that showed a good prediction of HCC-specific death at a specific time (t) were chosen. Internal and external validations with Uno's C-index were 0.79 and 0.75 (95% confidence interval (CI) 0.65-0.86), respectively. The predicted survival after liver transplantation for HCC (SALT) at a time "t" was calculated using the formula: [1 - (HCC-specific death(t'))] × 100. The 5-year HCC-specific death and recurrence rates in the low-risk group were 2% and 5%; the intermediate-risk group was 12% and 14%, and in the high-risk group were 71% and 82%. Our HCC-specific survival predictor named "SALT calculator" could provide accurate information about expected survival tailored for patients undergoing transplantation for HCC.
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http://dx.doi.org/10.3390/jcm10132869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8268829PMC
June 2021

"Reply to "Emergent liver transplantation for patients with acute-on-chronic liver failure"".

Dig Liver Dis 2021 Jun 25. Epub 2021 Jun 25.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

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http://dx.doi.org/10.1016/j.dld.2021.05.023DOI Listing
June 2021

Clinical Outcomes of Neoadjuvant Chemotherapy in Colorectal Cancer Patients With Synchronous Resectable Liver Metastasis: A Propensity Score Matching Analysis.

Ann Coloproctol 2021 Aug 29;37(4):244-252. Epub 2021 Jun 29.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Purpose: The survival benefit of neoadjuvant chemotherapy (NAC) prior to surgical resection in colorectal cancer with liver metastases (CRCLM) patients remains controversial. The aim of this study was to compare overall outcome of CRCLM patients who underwent NAC followed by surgical resection versus surgical treatment first.

Methods: We retrospectively analyzed 429 patients with stage IV colorectal cancer with synchronous liver metastases who underwent simultaneous liver resection between January 2008 and December 2016. Using propensity score matching, overall outcome between 60 patients who underwent NAC before surgical treatment and 60 patients who underwent surgical treatment first was compared.

Results: Before propensity score matching, metastatic cancer tended to involve a larger number of liver segments and the primary tumor size was bigger in the NAC group than in the primary resection group, so that a larger percentage of patients in the NAC group underwent major hepatectomy (P<0.001). After propensity score matching, demographic features and pathologic outcomes showed no significant differences between the 2 groups. In addition, there was no significant difference in short-term recovery outcomes such as postoperative morbidity (P=0.603) and oncologic outcome, including 3-year overall survival rate (P=0.285) and disease-free survival rate (P=0.730), between the 2 groups.

Conclusion: NAC prior to surgical treatment in CRCLM is considered a safe treatment that does not increase postoperative morbidity, and its impact on oncologic outcome was not inferior.
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http://dx.doi.org/10.3393/ac.2020.00710.0101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8391040PMC
August 2021

Prediction model for early graft failure after liver transplantation using aspartate aminotransferase, total bilirubin and coagulation factor.

Sci Rep 2021 Jun 18;11(1):12909. Epub 2021 Jun 18.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710, Korea.

This study was designed to build models predicting early graft failure after liver transplantation. Cox regression model for predicting early graft failure after liver transplantation using post-transplantation aspartate aminotransferase, total bilirubin, and international normalized ratio of prothrombin time was constructed based on data from both living donor (n = 1153) and deceased donor (n = 359) liver transplantation performed during 2004 to 2018. The model was compared with Model for Early Allograft Function Scoring (MEAF) and early allograft dysfunction (EAD) with their C-index and time-dependent area-under-curve (AUC). The C-index of the model for living donor (0.73, CI = 0.67-0.79) was significantly higher compared to those of both MEAF (0.69, P = 0.03) and EAD (0.66, P = 0.001) while C-index for deceased donor (0.74, CI = 0.65-0.83) was only significantly higher compared to C-index of EAD. (0.66, P = 0.002) Time-dependent AUC at 2 weeks of living donor (0.96, CI = 0.91-1.00) and deceased donor (0.98, CI = 0.96-1.00) were significantly higher compared to those of EAD. (both 0.83, P < 0.001 for living donor and deceased donor) Time-dependent AUC at 4 weeks of living donor (0.93, CI = 0.86-0.99) was significantly higher compared to those of both MEAF (0.87, P = 0.02) and EAD. (0.84, P = 0.02) Time-dependent AUC at 4 weeks of deceased donor (0.94, CI = 0.89-1.00) was significantly higher compared to both MEAF (0.82, P = 0.02) and EAD. (0.81, P < 0.001). The prediction model for early graft failure after liver transplantation showed high predictability and validity with higher predictability compared to traditional models for both living donor and deceased donor liver transplantation.
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http://dx.doi.org/10.1038/s41598-021-92298-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213713PMC
June 2021

Application of three-dimensional printing for intraoperative guidance during liver resection of a hepatocellular carcinoma with sophisticated location.

Ann Hepatobiliary Pancreat Surg 2021 May;25(2):265-269

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

While 3D printing is adapted usefully in certain field of surgery, its application in liver surgery was limited. Here, we introduce our experience for using 3D printing for intraoperative guidance during liver resection in a case for HCC with an intrahepatic metastasis at a sophisticated location. A 50 years old male patient was diagnosed 4.7 cm-sized hepatocellular carcinoma located on segment 3 with and an intrahepatic metastasis located on segment 8 which was between right anterior portal vein, middle hepatic vein and right hepatic vein. Since radiofrequency ablation appeared to be inappropriate, surgical resection was planned. However, the patient had a cirrhotic liver and left liver was estimated to be 47% according to volume measurement. Therefore, we planned a two-step procedure by performing left hemihepatectomy preserving the middle hepatic vein and additionally removing the intrahepatic metastasis by tumorectomy. For better guidance, we made a 3D printed model tailored for using it as a guidance during operation, and the accuracy of 3D-printed model helped the surgical team perform a safe operation. The patient underwent adjuvant proton beam therapy on the site of tumorectomy and did not experience recurrence.
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http://dx.doi.org/10.14701/ahbps.2021.25.2.265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180396PMC
May 2021

Adjuvant therapy using -expanded allogenic natural killer cells in hepatectomy patients with hepatitis B virus related solitary hepatocellular carcinoma: MG4101 study.

Ann Hepatobiliary Pancreat Surg 2021 May;25(2):206-214

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Backgrounds/aims: Fewer reports have been published regarding hepatectomy patients with solitary hepatocellular carcinoma (HCC) who received immunotherapeutic agents as adjuvant therapy. We evaluated the safety and efficacy of -expanded allogenic natural killer (NK) cells in those patients with modified International Union Against Cancer (UICC) stage T3.

Methods: From August 2014 to October 2015, five patients who underwent hepatic resection received -expanded allogenic NK cells. Patients received five rounds of NK cells (2-3×10 cells/kg) at postoperative 4, 6, 8, 12, and 16 weeks. This study is registered with ClinicalTrials.gov, number NCT02008929.

Results: The median age of the five patients (three men and two women) was 44.8 years (range, 36-54 years). All had hepatitis B virus-related HCC, and the median tumor size was 2.2 cm (range, 2.1-8.2 cm). None of the patients had any adverse events. HCC recurrence developed in two patients at one year after hepatic resection, but four patients were alive at 3 years. The two recurrence-free patients showed a higher ratio of CD8+ T lymphocyte populations before and after administration of -expanded allogenic NK cells compared with the three patients who experienced recurrence.

Conclusions: Immunotherapy using -expanded allogenic NK cells in hepatectomy patients can be used safely. Further studies should be investigated for efficacy.
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http://dx.doi.org/10.14701/ahbps.2021.25.2.206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180393PMC
May 2021

Quantitative analysis of contrast-enhanced ultrasonography following living donor liver transplantation: early diagnosis of middle hepatic venous occlusion.

Med Ultrason 2021 May 20. Epub 2021 May 20.

Department of Surgery, Samsung Medical Center.

Aim: This study aimed to evaluate whether a quantitative contrast-enhanced ultrasonography (CEUS) study is feasible to diagnose middle hepatic venous occlusion after living donor liver transplantation (LDLT).

Materials And Methods: From December 2018 to July 2019, the CEUS study on the first postoperative day had been conducted in patients who underwent LDLT. 46 patients were finally included in the study. To obtain CEUS parameters from time-intensity curves (TICs) on the hepaticparenchyma, the two regions of interests (ROIs) were located in the right hepatic vein (RHV) territory and middle hepatic vein (MHV) territory of the right hepatic graft. The measured CEUS parameters were wash-in slope (WIS), peak intensity (PI), time to peak (TTP), and area under the curve (AUC). The subjects were classified into the occlusion and non-occlusion groups. In each group, the parameters measured in the RHV and MHV territories were compared with paired-sample Student'st-tests.

Results: Hepatic venous occlusion was diagnosed in 25 patients (54%). The WIS, TTP, and AUC of the MHV territory (2.95 dB/sec; 22.39 sec; 204.27 dB·sec, respectively) were significantly different from those of the RHV territory (2.16 dB/sec; 25.81 sec; 165.66 dB·sec; all p<0.05). There were no statistically significant differences in PI between the MHV and RHV territories (19.08 dB vs. 18.27 dB, respectively; p=0.259). In the non-occlusion group, there was no parameter which was significantly different between MHV and RHV territories (p>0.05).

Conclusion: The parametric analysis of CEUS can help diagnose middle hepatic venous occlusion after LDLT.
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http://dx.doi.org/10.11152/mu-2906DOI Listing
May 2021

Predictors and outcome of emergent Liver transplantation for patients with acute-on-chronic liver failure.

Dig Liver Dis 2021 Aug 27;53(8):1004-1010. Epub 2021 Apr 27.

Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background And Aims: Controversy exists over whether emergent liver transplantation (LT) should be performed for patients with acute-on-chronic liver failure (ACLF), especially for patients with multiple organ failure.

Methods: A total of 110 ACLF patients, defined by the European Association for the Study of the Liver (EASL) Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) criteria were analyzed. The primary outcome was overall survival after ACLF diagnosis.

Results: During follow-up, 76 patients received LT (59 received deceased-donor LT and 17 patients received living-donor LT). The overall survival was better for patients who received LT than patients who did not (82.9% vs. 17.6%, P < 0.001). Among the 76 patients who received LT, the overall survival was not different according to ACLF grade at diagnosis (70.0%, 85.3%, and 84.4% at one-year for ACLF grades 1, 2, and 3, respectively, P = 0.45). The baseline model for end-stage liver disease (MELD) score and progression of the ACLF grade during the pre-transplant period were independent factors for survival after LT. The one-year survival rate was 92.3% for patients with baseline MELD scores of ≤ 32 without ACLF grade progression, whereas it was 33.3% for those with baseline MELD scores of > 32 and ACLF grade progression.

Conclusions: Emergent LT provided a significant survival benefit to ACLF patients, regardless of the baseline ACLF grade. Post-LT outcomes were associated with baseline MELD scores and ACLF progression during the pre-transplant period, which might be used in the emergent LT plan for patients presenting with ACLF.
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http://dx.doi.org/10.1016/j.dld.2021.03.030DOI Listing
August 2021

Postoperative outcomes of purely laparoscopic donor hepatectomy compared to open living donor hepatectomy: a preliminary observational study.

Ann Surg Treat Res 2021 Apr 30;100(4):235-245. Epub 2021 Mar 30.

Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Purpose: To lessen the physical, cosmetic, and psychological burden of donors, purely laparoscopic donor hepatectomy (PLDH) has been proposed as an ideal method for living donors. Our study aimed to prospectively compare the effect of PLDH and 2 other types of open living donor hepatectomy (OLDH) on postoperative pain and recovery.

Methods: Sixty donors scheduled to undergo donor hepatectomy between March 2015 and November 2017 were included. Donors were divided into 3 groups by surgical technique: OLDH with a subcostal incision (n = 20), group S; OLDH with an upper midline incision (n = 20), group M; and PLDH (n = 20), group L. The primary outcomes were postoperative pain and analgesic requirement during postoperative day (POD) 3. Other variables regarding postoperative recovery were also analyzed.

Results: Although pain relief during POD 3, assessed by visual analog scale (VAS) score and analgesic requirement, was similar among the 3 groups, group L showed lower VAS scores and opioid requirements than group M. Moreover, group L was associated with a rapid postoperative recovery evidenced by the shorter hospital length of stay and more frequent return to normal activity on POD 30.

Conclusion: This pilot study failed to verify the hypothesis that PLDH reduces postoperative pain. PLDH did not reduce postoperative pain but showed faster recovery than OLDH.
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http://dx.doi.org/10.4174/astr.2021.100.4.235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019986PMC
April 2021

Impact of Graft Weight Change During Perfusion on Hepatocellular Carcinoma Recurrence After Living Donor Liver Transplantation.

Front Oncol 2020 24;10:609844. Epub 2021 Feb 24.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.

Backgrounds: Inadequate liver volume and weight is a major source of morbidity and mortality after adult living donor liver transplantation (LDLT). The purpose of our study was to investigate HCC recurrence, graft failure, and patient survival according to change in right liver graft weight after histidine-tryptophan-ketoglutarate (HTK) solution perfusion in LDLT.

Methods: Two hundred twenty-eight patients underwent LDLT between 2013 and 2017. We calculated the change in graft weight by subtracting pre-perfusion graft weight from post-perfusion graft weight. Patients with increased graft weight were defined as the positive group, and patients with decreased graft weight were defined as the negative group.

Results: After excluding patients who did not meet study criteria, 148 patients underwent right or extended right hepatectomy. The negative group included 89 patients (60.1%), and the positive group included 59 patients (39.9%). Median graft weight change was -28 g (range; -132-0 g) in the negative group and 21 g (range; 1-63 g) in the positive group (P<0.001). Median hospitalization time was longer for the positive group than the negative group (27 days vs. 23 days; P=0.048). There were no statistical differences in tumor characteristics, postoperative complications, early allograft dysfunction, or acute rejection between the two groups. Disease-free survival, death-censored graft survival, and patient survival were lower in the positive group than the negative group. Additionally, the positive group showed strong association with HCC recurrence, death-censored graft survival, and patient survival in multivariate analysis.

Conclusion: This study suggests that positive graft weight change during HTK solution perfusion indicates poor prognosis in LDLT.
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http://dx.doi.org/10.3389/fonc.2020.609844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7945034PMC
February 2021

Laparoscopic Living Donor Right Hepatectomy Regarding the Anatomical Variation of the Portal Vein: A Propensity Score-Matched Analysis.

Liver Transpl 2021 07 24;27(7):984-996. Epub 2021 Jun 24.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

This study is designed to analyze the feasibility of laparoscopic living donor right hemihepatectomy in living donors with portal vein variation. Living donor liver transplantation cases using a right liver graft during the period of January 2014 to September 2019 were included. Computed tomographic angiographies of the donor were 3-dimensionally reconstructed, and the anatomical variation of the portal vein was classified. To reduce selection bias, a 1:1 ratio propensity score-matched analysis between the laparoscopy group and the open group was performed. Surgical and recovery-related outcomes as well as portal vein complication-free survival, graft survival, and overall survival rates were analyzed. After matching, 171 cases in each group from 444 original cases were compared. The laparoscopy group had a shorter operation time (P < 0.001), a smaller number of additional opioids required by the donor (P < 0.001), and a shorter hospital stay (P < 0.001). There were no differences in the portal vein complication-free survival (P = 0.16), graft survival (P = 0.26), or overall survival rates (P = 0.53). Although portal vein complication-free survival was inferior in portal veins other than type I (P = 0.01), the laparoscopy group showed similar portal vein complication-free survival regardless of the anatomical variation of portal vein (P = 0.35 in type I and P = 0.30 in other types). Laparoscopic living donor right hemihepatectomy can be performed as safely as open surgery regardless of the anatomical variation of the portal vein.
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http://dx.doi.org/10.1002/lt.26050DOI Listing
July 2021

Intraindividual Comparison of Hepatocellular Carcinoma Washout between MRIs with Hepatobiliary and Extracellular Contrast Agents.

Korean J Radiol 2021 05 2;22(5):725-734. Epub 2021 Feb 2.

Department of Mathematics, Ajou University, Suwon, Korea.

Objective: To intraindividually compare hepatocellular carcinoma (HCC) washout between MRIs using hepatobiliary agent (HBA) and extracellular agent (ECA).

Materials And Methods: This study included 114 prospectively enrolled patients with chronic liver disease (mean age, 55 ± 9 years; 94 men) who underwent both HBA-MRI and ECA-MRI before surgical resection for HCC between November 2016 and May 2019. For 114 HCCs, the lesion-to-liver visual signal intensity ratio (SIR) using a 5-point scale (-2 to +2) was evaluated in each phase. Washout was defined as negative visual SIR with temporal reduction of visual SIR from the arterial phase. Illusional washout (IW) was defined as a visual SIR of 0 with an enhancing capsule. The frequency of washout and MRI sensitivity for HCC using LR-5 or its modifications were compared between HBA-MRI and ECA-MRI. Subgroup analysis was performed according to lesion size (< 20 mm or ≥ 20 mm).

Results: The frequency of portal venous phase (PP) washout with HBA-MRI was comparable to that of delayed phase (DP) washout with ECA-MRI (77.2% [88/114] vs. 68.4% [78/114]; = 0.134). The frequencies were also comparable when IW was allowed (79.8% [91/114] for HBA-MRI vs. 81.6% [93/114] for ECA-MRI; = 0.845). The sensitivities for HCC of LR-5 (using PP or DP washout) were comparable between HBA-MRI and ECA-MRI (78.1% [89/114] vs. 73.7% [84/114]; = 0.458). In HCCs < 20 mm, the sensitivity of LR-5 was higher on HBA-MRI than on ECA-MRI (70.8% [34/48] vs. 50.0% [24/48]; = 0.034). The sensitivity was similar to each other if IW was added to LR-5 (72.9% [35/48] for HBA-MRI vs. 70.8% [34/48] for ECA-MRI; > 0.999).

Conclusion: Extracellular phase washout for HCC diagnosis was comparable between MRIs with both contrast agents, except for tumors < 20 mm. Adding IW could improve the sensitivity for HCC on ECA-MRI in tumors < 20 mm.
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http://dx.doi.org/10.3348/kjr.2020.1143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076831PMC
May 2021

Ultrasound-guided erector spinae plane block for postoperative analgesia in laparoscopic liver resection: A prospective, randomised controlled, patient and observer-blinded study.

Eur J Anaesthesiol 2021 08;38(Suppl 2):S106-S112

From the Department of Anesthesiology and Pain Medicine (DK, GH, GSK, JSJ) and Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (JMK, G-SC).

Background: Erector spinae plane block (ESPB) has been reported to manage postoperative pain effectively after various types of surgery. However, there has been a lack of study on the effect of ESPB after liver resection.

Objectives: To investigate the analgesic effects of ESPB on pain control after laparoscopic liver resection compared with conventional pain management.

Design: Prospective, randomised controlled study.

Setting: A single tertiary care centre from February 2019 to February 2020.

Patients: A total of 70 patients scheduled to undergo laparoscopic liver resection.

Interventions: In the control group (n = 35), no procedure was performed. In the ESPB group (n = 35), ESPB was performed after induction of general anaesthesia. A total of 40 ml of ropivacaine 0.5% was injected at the T9 level bilaterally. After surgery, intravenous fentanyl patient-controlled analgesia was initiated. Fentanyl and hydromorphone were administered as rescue analgesics.

Main Outcome Measures: The primary outcome was the cumulative postoperative opioid consumption at 24 h (morphine equivalent). The secondary outcomes were rescue opioid (fentanyl) dose in the postanaesthesia care unit (PACU) and pain severity at 1, 6, 12, 24, 48 and 72 h, assessed using a numerical rating scale (NRS) score.

Results: The median [IQR] postoperative opioid consumption during 24 hours following surgery was 48.2 [17.1] mg in the control group and 45.5 [35.8] mg in the ESPB group (median difference, 4.2 mg; 95% CI, -4.2 to 13.3 mg; P = 0.259). Conversely, rescue opioid in PACU was 5.3 [5.0] mg in the control group and 3.0 [1.5] mg in the ESPB group (median difference, 2.5 mg; 95% CI, 1.0 to 5.0 mg; P < 0.001). There was no significant difference in NRS scores point between the groups at any time.

Conclusion: ESPB does not provide analgesic effect within 24 h after laparoscopic liver resection.

Trial Registration: Clinical Trial Registry of Korea (https://cris.nih.go.kr.), identifier: KCT0003549).
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http://dx.doi.org/10.1097/EJA.0000000000001475DOI Listing
August 2021

Association between neutrophil-lymphocyte ratio change during living donor liver transplantation and graft survival.

Sci Rep 2021 Feb 18;11(1):4199. Epub 2021 Feb 18.

Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.

Preoperative neutrophil-lymphocyte ratio (NLR), has shown a predictive value in living donor liver transplantation (LDLT). However, the change in the NLR during LDLT has not been fully investigated. We aimed to compare graft survival between the NLR increase and decrease during LDLT. From June 1997 to April 2019, we identified 1292 adult LDLT recipients with intraoperative NLR change. The recipients were divided according to NLR change: 103 (8.0%) in the decrease group and 1189 (92.0%) in the increase group. The primary outcome was graft failure in the first year. In addition, variables associated with NLR change during LDLT were evaluated. During 1-year follow-up, graft failure was significantly higher in the decrease group (22.3% vs. 9.1%; hazard ratio 1.87; 95% confidence interval 1.10-3.18; p = 0.02), but postoperative complications did not differ between two groups. This finding was consistent for the overall follow-up. Variables associated with NLR decrease included preoperative NLR > 4, model for end-stage liver disease score, intraoperative inotropic infusion and red blood cell transfusion, and operative duration. The least absolute shrinkage and selection operator model yielded similar results. NLR decrease during LDLT appeared to be independently associated with graft survival. Further studies are needed to confirm our findings.
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http://dx.doi.org/10.1038/s41598-021-83814-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892541PMC
February 2021

Second generation laryngeal mask airway during laparoscopic living liver donor hepatectomy: a randomized controlled trial.

Sci Rep 2021 Feb 11;11(1):3532. Epub 2021 Feb 11.

Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.

The second-generation laryngeal mask airway (LMA) provides a higher sealing pressure than classical LMA and can insert the gastric drainage tube. We investigated the difference in respiratory variables according to the use of second-generation LMA and endotracheal tube (ETT) in laparoscopic living liver donor hepatectomy (LLDH). In this single-blind randomized controlled trial, intraoperative arterial carbon dioxide partial pressure at 2 h after the airway devices insertion (PCO2h) was compared as a primary outcome. Participants were randomly assigned to the following groups: Group LMA (n = 45, used Protector LMA), or Group ETT (n = 43, used cuffed ETT). Intraoperative hemodynamic and respiratory variables including mean blood pressure (MBP), heart rate (HR), and peak inspiratory pressure (PIP) were compared. Postoperative sore throat, hoarseness, postoperative nausea and vomiting (PONV), and pulmonary aspiration were recorded. The PCO2h were equally effective between two groups (mean difference: 0.99 mmHg, P = 0.003; 90% confidence limits: - 0.22, 2.19). The intraoperative change in MBP, HR, and PIP were differed over time between two groups (P < 0.001, P = 0.015, and P = 0.039, respectively). There were no differences of the incidence of postoperative complications at 24 h following LLDH (sore throat and hoarseness: P > 0.99, PONV: P > 0.99, and P = 0.65, respectively). No case showed pulmonary aspiration in both groups. Compared with endotracheal tube, second-generation LMA is equally efficient during LLDH. The second-generation LMA can be considered as the effective airway devices for securing airway in patients undergoing prolonged laparoscopic surgery. Trial Registration This study was registered at the Clinical Trial Registry of Korea ( https://cris.nih.go.kr . CRiS No. KCT0003711).
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http://dx.doi.org/10.1038/s41598-021-83173-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878811PMC
February 2021

Laparoscopic radiofrequency ablation of subcapsular hepatocellular carcinomas: risk factors related to a technical failure.

Surg Endosc 2021 Feb 1. Epub 2021 Feb 1.

Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-Gu, Seoul, 06351, Republic of Korea.

Background: This study aimed to evaluate the risk factors related to a technical failure after laparoscopic radiofrequency ablation (RFA) for subcapsular hepatocellular carcinomas (HCCs).

Materials And Methods: A total of 110 patients with 114 HCCs who underwent laparoscopic RFA for HCCs (new HCC [n = 85] and local tumor progression [LTP] [n = 29]) between January 2013 and December 2018 were included. We evaluated the incidence of technical failure on immediate post-RFA CT images. Risk factors for a technical failure after laparoscopic RFA were assessed using univariable logistic regression analyses. The cumulative LTP rate was estimated using the Kaplan-Meier method.

Results: Technical failure was noted in 3.5% (4/114) of the tumors. All four tumors that showed a technical failure were cases of LTP from previous treatment and were invisible on laparoscopy. On univariate analysis, LTP lesion, invisibility of the index tumor on laparoscopy, and peri-hepatic vein location of the tumor were identified as risk factors for a technical failure. The cumulative LTP rates at 1, 3, and 5 years were estimated to be 2.8%, 4.8%, and 4.8%, respectively.

Conclusions: LTP lesion, invisibility of the index tumor on laparoscopy, and peri-hepatic vein location of the tumor were identified as the risk factors for a technical failure after laparoscopic RFA.
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http://dx.doi.org/10.1007/s00464-021-08310-7DOI Listing
February 2021

An observational study on the effect of hypercholesterolemia developed after living donor liver transplantation on cardiac event and graft failure.

Sci Rep 2021 01 13;11(1):959. Epub 2021 Jan 13.

Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.

This study sought to evaluate the association between newly-developed significant hypercholesterolemia within one year following living donor liver transplantation (LDLT) and long term outcomes in light of cardiovascular events and graft failure. From October 2003 to July 2017, 877 LDLT recipients were stratified according to development of significant hypercholesterolemia within one year following LDLT. The primary outcome was occurrence of a major adverse cardiac event (MACE), defined as a composite of cardiac death, myocardial infarction, and coronary revascularization after LDLT. The incidence of graft failure, defined as all-cause death or retransplantation, was also compared. A total of 113 (12.9%) recipients developed significant hypercholesterolemia within one year. The differences in incidences of cardiac related events and graft related events began emerging significantly higher in the hypercholesterolemia group after 24 months and 60 months since the LDLT, respectively. After adjustment using the inverse probability of weighting, the hazard ratio (HR) for MACE was 2.77 (95% confidence interval (CI) 1.16-6.61; p = 0.02), while that for graft failure was 3.76 (95% CI 1.97-7.17, p < 0.001). A significant hypercholesterolemia after LDLT may be associated with cardiac and graft-related outcome; therefore, a further study and close monitoring of cholesterol level after LDLT is needed.
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http://dx.doi.org/10.1038/s41598-020-79673-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7806822PMC
January 2021

Initial experience with high-volume plasma exchange in patients with acute liver failure.

J Clin Apher 2021 Jun 5;36(3):379-389. Epub 2021 Jan 5.

Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.

Background/aims: High-volume plasma exchange (HVPE), defined as an exchange of 8 to 12 L per day per procedure or 15% of the ideal body weight with fresh frozen plasma, has shown promising results in improving the survival of patients with acute liver failure (ALF). However, clinical evidence is limited. The aim of this study was to report our initial experience using HVPE as a bridge treatment in patients with ALF.

Methods: We retrospectively reviewed 32 consecutive patients awaiting liver transplantation (LT) due to ALF between 2013 and 2020 at Samsung Medical Center in Korea. HVPE has been used for patients with ALF since May 2016 at our institution.

Results: During the study period, 16 patients received HVPE. After HVPE, coagulopathies (INR, 4.46 [2.32-6.02] vs 1.48 [1.33-1.76], P < .05), total bilirubin (22.6 [9.1-26.4] vs 8.9 [5.6-11.3], P < .05), alanine aminotransferase (506 [341-1963] vs 120 [88-315], P < .05), and ammonia levels (130.6 [123.7-143.8] vs 98.2 [84.2-116.5], P < .05) were improved. Improvement in the hepatic encephalopathy grade was observed in four patients. Among 16 patients who received HVPE, 12 patients were bridged to LT, and three patients recovered spontaneously. The overall survival was 94% and 69%, respectively at 30 days in patients who received and did not receive HVPE (P = .068). Among 18 patients with high chronic liver failure-sequential organ failure assessment scores (≥13), the overall survival was significantly better for those who received HVPE than for those who did not (91% vs 29%, respectively, at 30 days, P < .05).

Conclusions: Our initial clinical experience with HVPE suggests that HVPE can be a viable option in improving the outcomes of patients presenting with ALF.
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http://dx.doi.org/10.1002/jca.21873DOI Listing
June 2021

Clinical impact of anatomical resection on long-term outcomes after hepatectomy for primary solitary hepatocellular carcinoma with or without preoperative positron emission tomography positivity.

Ann Transl Med 2020 Nov;8(21):1377

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: There is little evidence indicating that anatomical resection (AR) is associated with improved survival in patients with solitary hepatocellular carcinoma (HCC) who were preoperatively evaluated by positron emission tomography (PET). The aim of our study was to compare the oncologic outcomes of AR in PET-positive versus PET-negative patients with HCC.

Methods: From January 2007 to September 2015, 259 patients with preoperative PET underwent hepatectomy as the primary treatment for solitary HCC. Patients were divided into four groups according to PET uptake and hepatectomy type [AR or non-anatomical resection (NAR)]: Group 1 (PET-negative and AR, n=62); Group 2 (PET-negative and NAR, n= 46); Group 3 (PET-positive and AR, n=100); Group 4 (PET-positive and NAR, n=51).

Results: PET positivity was associated with higher protein induced by vitamin K antagonist-II (P=0.025), lager tumor size (P=0.05), microvascular invasion (MVI) (P=0.012), and portal vein invasion (P=0.031). In Kaplan-Meier analysis for RFS, Group 1 showed remarkable difference from Group 3 and Group 4 (P=0.045, P=0.023, respectively). In the PET-positive subgroup with HCC under 3 cm, AR was associated with better RFS than NAR (P=0.016).

Conclusions: A combination of AR and PET negativity showed good prognosis in long-term outcomes. Finally, AR can decrease the risk of tumor recurrence in patients with a solitary PET-positive HCC less than 3 cm.
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http://dx.doi.org/10.21037/atm-20-1583DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7723622PMC
November 2020

Venous outflow congestion is related to poor recurrence-free survival of living donor liver transplantation recipients with hepatocellular carcinoma - a retrospective study.

Transpl Int 2021 02 12;34(2):272-280. Epub 2020 Dec 12.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

This study analyzed the impact of venous outflow congestion in the liver graft on hepatocellular carcinoma recurrence in liver transplantation recipients. Hepatocellular carcinoma patients who underwent living donor liver transplantation at Samsung Medical Center between 2007 and 2018 were included. The congested volume was calculated based on 2-week post-transplantation computed tomography. Recurrence-free survival and overall survival were analyzed using the multivariable Cox proportional hazard model including the degree of venous congestion. A total of 582 patients were included. There were 232 patients (39.9%) with certain degree of congestion volume. Kaplan-Meier survival analyses showed 1-, 5-, and 10-year recurrence-free survivals of 86.0%, 72.2%, and 70.7%, respectively, and overall survivals of 91.5%, 73.4%, and 68.9%, respectively. While congestion volume per 10 cm was a significant risk factor for recurrence-free survival (HR = 1.024, CI: 1.002-1.047, P = 0.034), there was no significant relationship with overall survival. (HR = 1.015, CI: 0.992-1.039, P = 0.213). Venous outflow congestion in the liver after living donor liver transplantation was related to the poor recurrence-free survival of hepatocellular carcinoma patients.
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http://dx.doi.org/10.1111/tri.13792DOI Listing
February 2021

Serial Observations of Muscle and Fat Mass as Prognostic Factors for Deceased Donor Liver Transplantation.

Korean J Radiol 2021 02 3;22(2):189-197. Epub 2020 Nov 3.

Department of Preventive Medicine, College of Medicine, Chungbuk National University, Cheongju, Korea.

Objective: Muscle depletion in patients undergoing liver transplantation affects the recipients' prognosis and therefore cannot be overlooked. We aimed to evaluate whether changes in muscle and fat mass during the preoperative period are associated with prognosis after deceased donor liver transplantation (DDLT).

Materials And Methods: This study included 72 patients who underwent DDLT and serial computed tomography (CT) scans. Skeletal muscle index (SMI) and fat mass index (FMI) were calculated using the muscle and fat area in CT performed 1 year prior to surgery (1 yr Pre-LT), just before surgery (Pre-LT), and after transplantation (Post-LT). Simple aspects of serial changes in muscle and fat mass were analyzed during three measurement time points. The rate of preoperative changes in body composition parameters were calculated (preoperative ΔSMI [%] = [SMI at Pre-LT - SMI at 1 yr Pre-LT] / SMI at Pre-LT × 100; preoperative ΔFMI [%] = [FMI at Pre-LT - FMI at 1 yr Pre-LT] / FMI at Pre-LT × 100) and assessed for correlation with patient survival.

Results: SMI significantly decreased during the preoperative period (mean preoperative ΔSMI, -13.04%, < 0.001). In the multivariable analysis, preoperative ΔSMI ( = 0.016) and model for end-stage liver disease score ( = 0.011) were independent prognostic factors for overall survival. The mean survival time for patients with a threshold decrease in the preoperative ΔSMI (≤ -30%) was significantly shorter than for other patients ( = 0.007). Preoperative ΔFMI was not a prognostic factor but FMI increased during the postoperative period ( = 0.009) in all patients.

Conclusion: A large reduction in preoperative SMI was significantly associated with reduced survival after DDLT. Therefore, changes in muscle mass during the preoperative period can be considered as a prognostic factor for survival after DDLT.
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http://dx.doi.org/10.3348/kjr.2019.0750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817639PMC
February 2021

Image guidance using two-dimensional illustrations and three-dimensional modeling of donor anatomy during living donor hepatectomy.

Clin Transplant 2021 01 12;35(1):e14164. Epub 2020 Dec 12.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: For living donor liver transplantation, preoperative imaging is required for the safety of both the donor and the recipient. We previously initiated our image-guidance program using two-dimensional illustrations and three-dimensional modeling in September 2018; herein, we analyzed the resultant changes in the clinical outcomes.

Methods: Living donors and recipients who underwent liver transplantation between September 2017 and August 2019 were included. Cases with image guidance were compared to those without image guidance regarding the operative outcome, especially bile-duct opening in the graft as well as surgical complications.

Results: Among 200 living donor transplantation, 90 transplantations were completed with image guidance. The image-guidance group had a higher rate of laparoscopy (80.9% vs. 97.8%; p < .001) as compared with the group without image guidance. Although there was no difference in the type of bile duct (p = .144), more grafts with single bile-duct openings were found in the image-guidance group (52.7% vs. 80.0%; p = .001). Consequently, achievements in bile-duct openings were superior in the image-guidance group (p = .022). There were no differences in bile leakage, graft failure, or number of deaths during the first month post-transplantation.

Conclusion: As we initiated our image-guidance program for living donor liver transplantation, clinical outcomes, especially bile-duct division, were improved relative to before implementation.
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http://dx.doi.org/10.1111/ctr.14164DOI Listing
January 2021

Poor outcomes of early recurrent post-transplant bloodstream infection in living-donor liver transplant recipients.

Eur J Clin Microbiol Infect Dis 2021 Apr 21;40(4):771-778. Epub 2020 Oct 21.

Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.

Bloodstream infection (BSI) is a common complication after living-donor liver transplantation (LDLT). Some patients develop recurrent BSIs. We evaluated the impacts of early recurrent BSIs (ER-BSIs) on outcomes in LDLT recipients. LDLT cases between 2008 and 2016 were included. Early BSI (E-BSI) was defined as a BSI event that occurred within 2 months after LDLT. ER-BSIs were defined as new-onset BSIs within 2 months due to another pathogen at a ≥ 48-h interval or a relapse of BSIs by the same pathogen at a ≥ 1-week interval, with negative cultures in between. The primary objective was evaluating the all-cause mortality of each group of LDLT recipients (90 days and 1 year). The secondary objectives were analyzing associated factors of each all-cause mortality and risk factors for early single BSI and ER-BSI. Among 727 LDLT recipients, 108 patients experienced 149 events of E-BSI with 170 isolated pathogens. Twenty-eight patients (25.9%, 28/108) experienced ER-BSI. The 1-year survival rates of patients without BSI, with early single BSI event, and with ER-BSIs were 92.4%, 81.3%, and 28.6%, respectively. ER-BSI was the most significant risk factor for 1-year mortality (adjusted HR = 5.31; 95% CI = 2.27-12.40). Intra-abdominal and/or biliary complications and early allograft dysfunction were risk factors for both early single BSI and ER-BSI. Interestingly, longer cold ischemic time and recipient operative time were associated with ER-BSI. LDLT recipients with ER-BSI showed very low survival rates accompanied by intra-abdominal complications. Clinicians should prevent BSI recurrence by being aware of intra-abdominal complications.
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http://dx.doi.org/10.1007/s10096-020-04074-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577647PMC
April 2021
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