Publications by authors named "Jong Man Kim"

331 Publications

Can hepatocellular carcinoma recurrence be prevented after liver transplantation?

Authors:
Jong Man Kim

Clin Mol Hepatol 2021 Sep 23. Epub 2021 Sep 23.

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

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http://dx.doi.org/10.3350/cmh.2021.0276DOI Listing
September 2021

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

Clinical impact of the treatment modality on small, solitary, recurrent intrahepatic hepatocellular carcinomas after primary liver resection.

Ann Surg Treat Res 2021 Aug 29;101(2):85-92. Epub 2021 Jul 29.

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

Purpose: The aim of this study was to determine the survival benefit based on different treatment strategies in patients with small, solitary, recurring intrahepatic hepatocellular carcinomas (HCCs) that were defined as recurred Barcelona Clinic Liver Cancer stage O (reBCLC-O).

Methods: Among the 917 patients with HCC recurrence after primary hepatic resection, 394 patients with reBCLC-O were selected. Of these, 150 patients underwent curative treatment (re-resection, radiofrequency ablation, and liver transplantation) and 203 underwent transarterial chemoembolization (TACE) group for recurrent HCC. After propensity score matching (PSM), both the groups were well balanced (89 patients in each group).

Results: Before PSM, the 1-, 3-, and 5-year overall survival (OS) rates of patients in the curative treatment group (96.7%, 78.6%, and 70.5%, respectively) were significantly better than those in the TACE treatment group (95.6%, 53.7%, and 44.2%, respectively) (P < 0.001). After PSM, the 1-, 3-, and 5-year OS rates also differed significantly (92.0%, 79.6%, and 71.1% in the curative treatment group vs. 88.8%, 65.6%, and 57.9% in the TACE group) (P = 0.005). The independent predictors of worse OS were tumor number at the time of resection and treatment modality for the recurrence, time interval to recurrence, and prothrombin time international normalized ratio and alpha-fetoprotein levels at the time of recurrence.

Conclusion: The OS of patients in the curative treatment group was better than that in the non-curative treatment group after PSM. Based on our results, curative treatment should be strongly recommended in the patients with reBCLC-O recurrence for better survival.
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http://dx.doi.org/10.4174/astr.2021.101.2.85DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8331554PMC
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

Self-assembly using a retro Diels-Alder reaction.

Nat Commun 2021 07 9;12(1):4207. Epub 2021 Jul 9.

Department of Chemical Engineering, Hanyang University, Seoul, Korea.

Despite their great utility in synthetic and materials chemistry, Diels-Alder (DA) and retro Diels-Alder (rDA) reactions have been vastly unexplored in promoting self-assembly processes. Herein we describe the first example of a retro Diels-Alder (rDA) reaction-triggered self-assembly method. Release of the steric bulkiness associated with the bridged bicyclic DA adduct by the rDA reaction allowed generation of two building blocks that spontaneously self-assembled to form a supramolecular polymer. By employing photopolymerizable lipid building blocks, we demonstrated the efficiency of the rDA-based self-assembly strategy. Generation of reactive functional groups (maleimide and furan) that can be used for further modification of the supramolecular polymer is an additional meritorious feature of the rDA-based approach. Advantage was taken of reactive functional groups to fabricate stimulus-responsive selective and tunable colorimetric sensors. The strategy developed in this study should be useful for the design of systems that participate in triggered molecular assembly.
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http://dx.doi.org/10.1038/s41467-021-24492-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8270933PMC
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

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

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

Surgical treatment outcomes of primary hepatic sarcomas: A single-center experience.

World J Hepatol 2021 May;13(5):584-594

Department of Surgery, Samsung Medical Center, Seoul 06351, South Korea.

Background: Primary hepatic sarcoma is a rare tumor originated from mesenchymal tissue. There are various pathologic types of primary hepatic sarcoma and the treatment outcome of this tumor was usually disappointing. Unlike hepatocellular carcinoma, outcome of primary hepatic sarcoma is not well-known due to it's rarity. However, with development of medical technology, surgical treatment may lead to better survival.

Aim: To investigate the surgical outcomes of primary hepatic sarcoma, we gathered and analyzed the cases of a single institute.

Methods: From August 2001 to September 2016, a total of nine patients were surgically treated for primary hepatic sarcoma after exclusion of cases with open and closure, early loss to follow-up and sarcomatoid hepatocellular carcinoma and sarcomatoid cholangiocellular carcinoma. Baseline characteristics, tumor characteristics such as tumor pathology, size and number, surgical and adjuvant treatments were reviewed. Tumor recurrence, and patient survival were analyzed with retrospective approach.

Results: The enrolled participants included five patients with angiosarcoma and four patients with undifferentiated sarcoma. All patients experienced tumor recurrence at a median of 52 post-operative days. Only two patients survived and the 5-year survival rate was 29.6%. One patient with angiosarcoma who received central hepatectomy for primary tumor and received radiofrequency ablation for recurrent tumor still lives for 11 years. One patient with undifferentiated sarcoma received Rt. lobectomy for primary tumor followed by chemotherapy and radiation therapy still lives around 30 mo even though she got additional operation for recurrent tumor. Two patients who received living donor liver transplantation due to angiosarcoma died. Only adjuvant therapy was associated with survival gain ( = 0.002).

Conclusion: Patients with primary hepatic sarcoma may gain survival benefit with surgical resection followed by adjuvant therapy, even though the outcome remains relatively poor.
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http://dx.doi.org/10.4254/wjh.v13.i5.584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173340PMC
May 2021

Comparison of intragastric pressure between endotracheal tube and supraglottic airway devices in laparoscopic hepatectomy: A randomized, controlled, non-inferiority study.

Medicine (Baltimore) 2021 Jun;100(24):e26287

Department of Anaesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine.

Background: Supraglottic airway (SGA) devices do not definitively protect the airway from regurgitation of gastric contents. Increased gastric pressure and long operation time are associated with development of complications such as aspiration pneumonia. The aim of this study was to compare intragastric pressure between second-generation SGA and endotracheal tube (ETT) devices during long-duration laparoscopic hepatectomy.

Methods: A total of 66 patients was randomly assigned to 2 groups; 33 patients each in the ETT and SGA groups. Intragastric pressure was continuously measured via a gastric drainage tube with a three-way stopcock connected to the pressure monitoring device. Normal saline was added to the end of the gastric drainage tube at each operation time point.

Results: Intragastric pressure during pneumoperitoneum was no different between the 2 groups (P = .146) or over time (P = .094). The mean (standard deviation [SD]) pH of the SGA tip measured after operation was 6.7 (0.4), and a pH <4 was not observed. Relative risk of postoperative complications was significantly higher in the ETT group relative to the SGA group (sore throat, 5.5; cough,13.0).

Conclusions: Use of SGA devices does not further increase intragastric pressure, even during prolonged upper abdominal laparoscopic surgery. Also, the frequency of postoperative sore throat and cough was significantly lower when the second-generation SGA device was used.
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http://dx.doi.org/10.1097/MD.0000000000026287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213319PMC
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

Sex difference in the tolerance of hepatic ischemia-reperfusion injury and hepatic estrogen receptor expression according to age and macrosteatosis in healthy living liver donors.

Transplantation 2021 Feb 22. Epub 2021 Feb 22.

1From the Department of Anesthesiology and Pain Medicine 2 Department of Surgery Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea 3From the Department of Obstetrics and Gynecology, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea 4Statistics and Data Center, Samsung Medical Center, Seoul, Korea 5 Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: Hepatic estrogen signaling, which is important in liver injury/recovery, is determined by the level of systemic estrogen and hepatic estrogen receptor. We aimed to evaluate whether female's advantage in the tolerance of hepatic ischemia-reperfusion injury decreases according to the age of 40 y (systemic estrogen decrease) and macrosteatosis (hepatic estrogen receptor decrease).

Methods: We included 358 living liver donors (128 females and 230 males). The tolerance of hepatic ischemia-reperfusion injury was determined by the slope of the linear regression line modeling the relationship between the duration of intraoperative hepatic ischemia and the peak postoperative transaminase level. Estrogen receptor content was measured in the biopsied liver samples using immunohistochemistry.

Results: In the whole cohort, the regression slope for aspartate transaminase was comparable between females and males (P=0.940). Within the subgroup of ≤40 y donors, the regression slope was significantly smaller in females (P=0.031), whereas it was comparable within >40 y donors (P=0.867). Within the subgroup of ≤40 y non-macrosteatotic donors, the regression slope was significantly smaller in females in univariable (P=0.002) and multivariable analysis (P=0.006), whereas the sex difference was not found within ≤40 y macrosteatotic donors (P=0.685). Estrogen receptor content was significantly greater in females within ≤40 y non-macrosteatotic donors (P=0.021), whereas it was not different in others of >40 y or with macrosteatosis (P=0.450).

Conclusions: The tolerance of hepatic ischemia-reperfusion injury was greater in females than in males only when they were <40 y and without macrosteatosis. The results were in agreement with hepatic estrogen receptor immunohistochemistry study.
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http://dx.doi.org/10.1097/TP.0000000000003705DOI Listing
February 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

Blood Salvage and Autotransfusion Does Not Increase the Risk of Tumor Recurrence After Liver Transplantation for Advanced Hepatocellular Carcinoma.

Ann Surg 2021 Mar 18. Epub 2021 Mar 18.

*Department of Anesthesiology and Pain Medicine and †Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea ‡Statistics and Data Center, Samsung Medical Center, Seoul, Korea; †Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA §XXXX ¶Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.

Objective: To determine whether autotransfusion of salvaged blood with single leukoreduction is associated with post-transplant tumor recurrence in patients with advanced hepatocellular carcinoma (HCC).

Background: Previous studies have consistently demonstrated the safety of autotransfusion of salvaged and leukoreduced blood during liver transplantation for HCC. However, the effects of this technique remained unknown for advanced HCC.

Methods: Of 349 patients who underwent living donor liver transplantation for advanced HCC: 74/129 without autotransfusion were matched with 74/220 with autotransfusion using propensity score based on tumor biology, allogeneic transfusion, and others. Survival analysis was performed with death as a competing risk event. The primary outcome was HCC recurrence.

Results: Recipients in autotransfusion group received 811 (497-1247) mL of salvaged blood with single leukoreduction. In the matched cohort, cumulative overall recurrence probability at 1/2/5 years after transplantation was 24.6%/38.3%/39.7% for non-autotransfusion group and 16.2%/23.1%/32.5% for autotransfusion group. There were no significant differences between the two groups in overall recurrence (hazard ratio [HR] = 0.72 [0.43-1.21]), intrahepatic recurrence (HR = 0.70 [0.35-1.40]), and extrahepatic recurrence (HR = 0.82 [0.46-1.47]). Also, there were no significant differences in overall death (HR = 0.57 [0.29-1.12]), HCC-related death (HR = 0.59 [0.29-1.20]), and HCC-unrelated death (HR = 0.48 [0.09-2.65]).

Conclusion: When allogeneic transfusion was matched, autotransfusion was not significantly related to HCC recurrence, with more favorable probabilities for autotransfusion, in patients with advanced HCC. Thus, blood salvage and autotransfusion could be safely used with single leukoreduction, without double-filtered leukoreduction, during liver transplantation for HCC with potential benefits from avoiding allogeneic red blood cell transfusion.
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http://dx.doi.org/10.1097/SLA.0000000000004866DOI Listing
March 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

A comparative study of postoperative outcomes between minimally invasive living donor hepatectomy and open living donor hepatectomy: The Korean organ transplantation registry.

Surgery 2021 07 10;170(1):271-276. Epub 2021 Apr 10.

Department of Surgery, Jeonbuk National University Medical School, Jeonju, Korea. Electronic address:

Background: This study evaluated the safety and effectiveness of minimally invasive living donor hepatectomy in comparison with the open procedure, using Korean Organ Transplantation Registry data.

Methods: We reviewed the prospectively collected data of all 1,694 living liver donors (1,071 men, 623 women) who underwent donor hepatectomy between April 2014 and December 2017. The donors were grouped on the basis of procedure type to the minimally invasive procedure group (n = 304) or to the open procedure group (n = 1,390) and analyzed the relationships between clinical data and complications.

Results: No donors died after the procedure. The overall complication rates after operation in the minimally invasive procedure group and the open procedure group were 6.2% and 3.5%, respectively. Biliary complications were the most frequent events in both groups (minimally invasive procedure group, 2.4%; open procedure group, 1.6%). The majority of complications occurred within 7 days after surgery in both groups. The duration of hospitalization was shorter in the minimally invasive procedure group than in the open procedure group (9.04 ± 3.78 days versus 10.29 ± 4.01 days; P < .05).

Conclusion: Based on its similar outcomes in our study, minimally invasive donor hepatectomy cannot be an alternative option compared with the open procedure method. To overcome this, we need to ensure better surgical safety, such as lower complication rate and shorter duration of hospitalization.
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http://dx.doi.org/10.1016/j.surg.2021.03.002DOI Listing
July 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

Laparoscopic Liver Resection versus Percutaneous Radiofrequency Ablation for Small Single Nodular Hepatocellular Carcinoma: Comparison of Treatment Outcomes.

Liver Cancer 2021 Feb 14;10(1):25-37. Epub 2021 Jan 14.

Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea.

Background: Treatment outcomes of laparoscopic liver resection (LLR) and percutaneous radiofrequency ablation (p-RFA) for small single hepatocellular carcinomas (HCCs) have not yet been fully compared. The aim of this study was to compare LLR and p-RFA as first-line treatment options in patients with single nodular HCCs ≤3 cm.

Methods: From January 2014 to December 2016, a total of 566 patients with single nodular HCC ≤3 cm treated by either LLR ( = 251) or p-RFA ( = 315) were included. The recurrence-free survival (RFS) and cumulative incidence of local tumor progression (LTP) were estimated using Kaplan-Meier methods and compared using the log-rank test. Treatment outcome of 2 treatment modalities was compared in the subgroup of patients according to the tumor location.

Results: There were no significant differences in overall survival between LLR and p-RFA ( = 0.160); however, 3-year RFS was demonstrated to be significantly higher after LLR (74.4%) than after p-RFA (66.0%) ( = 0.013), owing to its significantly lower cumulative incidence of LTP (2.1% at 3 years after LLR vs. 10.0% after p-RFA, < 0.001). The complication rate of p-RFA was significantly lower than that of LLR (5.1 vs. 10.0%, = 0.026). LLR also provided significantly better local tumor control than p-RFA for subscapular tumors (3-year LTP rates: 1.9 vs. 8.8%, = 0.012), perivascular tumors (3-year LTP rates: 0.0 vs. 17.2%, = 0.007), and tumors located in anteroinfero-lateral liver portions (3-year LTP rates: 0.0 vs. 10.7%, < 0.001). However, there were no significant differences in LTP rates between LLR and p-RFA for non-subcapsular and non-perivascular tumors ( = 0.482) and for tumors in postero-superior liver portions ( = 0.380).

Conclusions: LLR can provide significantly better local tumor control than p-RFA for small single HCCs in subcapsular, perivascular, and anteroinferolateral liver portions and thus may be the preferred treatment option for these tumors.
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http://dx.doi.org/10.1159/000510909DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923879PMC
February 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

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

Outcomes after liver transplantation in Korea: Incidence and risk factors from Korean transplantation registry.

Clin Mol Hepatol 2021 Jul 2;27(3):451-462. Epub 2021 Feb 2.

Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.

Background/aims: To analyze the incidence and risk factors of outcomes after liver transplantation (LT) in the Korean population.

Methods: This study analyzed data from the liver cohort of Korean Organ Transplantation Registry (KOTRY) who had LT between May 2014 and December 2017. Study measures included the incidence of post-LT outcomes in recipients of living donor LT (LDLT) and deceased donor LT (DDLT). Cox multivariate proportional hazards model was used to determine the potential risk factors predicting the outcomes.

Results: A total of 2,563 adult recipients with LT (LDLT, n=1,956; DDLT, n=607) were included, with mean±standard deviation age of 53.9±8.9 years, and 72.2% were male. The post-LT outcomes observed in each LDLT and DDLT recipients were death (4.0% and 14.7%), graft loss (5.0% and 16.1%), rejection (7.0% and 12.0%), renal failure (2.7% and 13.8%), new onset of diabetes (12.5% and 15.4%), and hepatocellular carcinoma (HCC) recurrence (both 6.7%). In both LDLT and DDLT recipients, the most common post-LT complications were renal dysfunction (33.6% and 51.4%), infection (26.7% and 48.4%), and surgical complication (22.5% and 23.9%). Incidence of these outcomes were generally higher among recipients of DDLT than LDLT. Multivariate analysis indicated recipient age and DDLT as significant risk factors associated with death and graft loss. DDLT and ABO incompatible transplant were prognostic factors for rejection, and HCC beyond Milan criteria at pre-transplant was a strong predictor of HCC recurrence.

Conclusion: This study is a good indicator of the post-LT prognosis in the Korean population and suggests a significant burden of post-LT complications.
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http://dx.doi.org/10.3350/cmh.2020.0292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8273644PMC
July 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

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
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