Publications by authors named "Kwang-Woong Lee"

189 Publications

Minimally Invasive Living Donor Liver Transplantation: Pure Laparoscopic Explant Hepatectomy and Graft Implantation Using Upper Midline Incision.

Liver Transpl 2021 Apr 10. Epub 2021 Apr 10.

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

Minimally invasive approaches, including laparoscopic procedures, have increasingly been applied in surgery due to their advantages such as reduced surgical trauma, a better quality of life, shorter hospital stay, and less postoperative morbidity compared with open surgeries. Minimally invasive approaches in liver transplantation (LT) may have similar advantages for the recipients, including less pain and a shorter hospital stay, which could facilitate rehabilitation.
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http://dx.doi.org/10.1002/lt.26066DOI Listing
April 2021

Clinical usefulness of T1-weighted MR cholangiography with Gd-EOB-DTPA for the evaluation of biliary complication after liver transplantation.

Ann Hepatobiliary Pancreat Surg 2021 Feb;25(1):39-45

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

Backgrounds/aims: Biliary complications continue to be the major morbidity and mortality causes following living donor liver transplantation (LT). Endoscopic retrograde cholangiopancreatography (ERCP) has been performed to identify the biliary leakage source. However, this can lead to retrograde cholangitis and pancreatitis, and is not sufficient to diagnose bile leakage from cuts' surface. This study aimed to describe the use of T1-Weighted Magnetic Resonance (MR) Cholangiography with Gd-EOB-DTPA (Primovist) examination for evaluating the bile duct complication following LT.

Methods: From March 2012 to December 2018, 869 adult LT were performed at the Seoul National University Hospital. Forty-three recipients had undergone MR Cholangiography with Gd-EOB-DTPA. We reviewed these cases with their clinical outcomes and described the utility of the MR cholangiography with Gd-EOB-DTPA.

Results: In radiologic examinations performed in the patients suspected of bile duct complication, 95% had bile leakage and stricture. Cut surface leakage was diagnosed in two cases, and biliary leakage from the anastomosis site was diagnosed in the others. Most patients with leakage had undergone percutaneous drainage and ERCP, which was performed to evaluate the bile secretion function of the hepatocytes. There was no contrast-enhanced bile duct image in one case with severe rejection, and it might have been related to hepatocyte secretary dysfunction.

Conclusions: T1-Weighted MR Cholangiography with Gd-EOB-DTPA 40-minute delay examination is a feasible and safe non-invasive procedure for identifying biliary leakage sites.
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http://dx.doi.org/10.14701/ahbps.2021.25.1.39DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952671PMC
February 2021

Hepatic fibrosis grading with extracellular volume fraction from iodine mapping in spectral liver CT.

Eur J Radiol 2021 Apr 16;137:109604. Epub 2021 Feb 16.

Department of Surgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03087, Republic of Korea.

Purpose: To determine whether hepatic extracellular volume fraction (ECV) obtained from iodine density map (ECV-iodine) can be used to estimate hepatic fibrosis grade and to compare performance with ECV measured using Hounsfield units (ECV-HU).

Methods: From December 2016 to March 2019, patients who underwent liver resection or biopsy within four weeks after spectral liver CT were included. ECV-iodine and ECV-HU were calculated using the equilibrium phase. Within each of these, comparison of ECVs was made for different fibrosis grades (F0 - 1 vs. F2 - 3 vs. F4) and also for patients with compensated and decompensated cirrhosis. The diagnostic performance of ECVs in detecting clinically significant fibrosis (≥ F2) and cirrhosis (F4) was assessed using ROC analysis.

Results: A total of 144 patients (men = 98, mean age 58.1 ± 11.5 years) were included. The ECV-iodine value was significantly higher in cirrhosis (33.6 ± 6.8 %) than those with F0 - 1 (25.0 ± 3.7 %) or F2 - 3 (28.3 ± 3.4 %, P < 0.001 for all). It was significantly higher in decompensated cirrhosis than those with compensated cirrhosis (36.5 ± 7.2 % vs. 30.7 ± 5.0 %, respectively; P < 0.001). The AUC of ECV-iodine was 0.82 for detecting F2 or above (cut-off value, > 26.9 %) and 0.81 for detecting cirrhosis (cut-off value, > 29 %). ECV-iodine had a significantly higher AUC than ECV-HU for detecting F2 or above (AUC: 0.69, P <  0.001) and cirrhosis (AUC: 0.74, P =  0.04).

Conclusions: ECV-iodine from spectral CT was able to detect clinically significant hepatic fibrosis and cirrhosis.
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http://dx.doi.org/10.1016/j.ejrad.2021.109604DOI Listing
April 2021

Demarcating the exact midplane of the liver using indocyanine green near-infrared fluorescence imaging during laparoscopic donor hepatectomy.

Liver Transpl 2021 Feb 14. Epub 2021 Feb 14.

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

Background: Indocyanine green (ICG) near-infrared fluoroscopy has been recently implemented in pure laparoscopic donor hepatectomy (PLDH). The aims of this study are to quantitatively evaluate the effectiveness of ICG fluoroscopy during liver midplane dissection in PLDH and to demonstrate that a single injection of ICG is adequate for completion of both midplane dissection and bile duct division.

Method: Retrospective analysis was done with laparoscopic images acquired from video recordings of donors who underwent pure laparoscopic right or left hepatectomies performed without ICG (Pre-ICG group) from November 2015 to May 2016 and with ICG (Post-ICG group) from June 2016 to May 2017.

Results: 30 donors from the Pre-ICG group were compared to 46 donors from the Post-ICG group. The operation time was shorter (P=0.002) and post-operative peak aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were lower (P=0.031 and P=0.019, respectively) in the Post-ICG group than the Pre-ICG group. Within the Post-ICG group, the color intensity differences between the clamped vs. non-clamped regions in the natural, black-and-white, and fluorescent camera modes were 39.7±36.2, 89.6±46.9, and 19.1±36.8 (P<0.001), respectively. The luminosity differences were 37.2±34.5, 93.8±32.1, and 26.7±25.7 (P<0.001), respectively. In addition, the time from when ICG was injected to when the near-infrared camera was turned on for bile duct visualization was 85.6±25.8 mins. The time from when the near-infrared camera was turned on for bile duct visualization to when bile duct division was completed was 8.7±4.8 mins. All grafts received from the 46 donors were successfully transplanted.

Conclusion: ICG fluoroscopy helps to reduce operation time and lower post-operative peak AST/ALT levels. Furthermore, ICG injection visualized with black-and-white imaging is most effective for demarcating the exact liver midplane during PLDH. Also, a single intravenous injection of low-dose ICG is sufficient for midplane dissection as well as bile duct division.
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http://dx.doi.org/10.1002/lt.26019DOI Listing
February 2021

No diffuse intrahepatic biliary stricture after ABO-incompatible adult living donor liver transplantation using tailored rituximab-based desensitization protocol.

Ann Transl Med 2021 Jan;9(1):30

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

Background: Rituximab (RTx) desensitization protocol offered good outcome in ABO-incompatible (ABOi) living donor liver transplantation (LDLT). However, diffuse intrahepatic biliary stricture (DIHBS) is still inevitable hurdle. We selectively added postoperative high dose intravenous immunoglobulin (IVIG) and/or simultaneous splenectomy if ABO isoagglutinin titer just before liver transplantation after plasma exchange (PE) was higher than 1/16. Herein, we reported the excellent outcome of ABOi LDLT without DIHBS using tailored desensitization protocol and compared it with that of ABO-compatible (ABOc) LDLT.

Methods: Sixty-five cases (14.8%) of ABOi LDLTs were performed among 438 primary adult LDLTs in our center between March 2012 and June 2017. We performed 1-to-2 propensity score matching (PSM) to extract 60 cases of ABOi LDLTs and 120 cases of ABOc LDLTs.

Results: There were no significant differences in clinical characteristics between ABOi and ABOc recipients. There were no significant differences in complications and rejection. There was no DIHBS in both groups. The 1-, 3-, and 5-year overall survival rates were 98.3%, 86.7%, and 82.9% in ABOi group and 96.7%, 86.7%, and 85.4% in ABOc group, respectively (P=0.88). Most common cause of deaths of both groups was hepatocellular recurrence. The 1-, 3-, and 5-year biliary complication (anastomosis leakage or stricture) free survival rates were 81.4%, 69.5%, and 67.5% in ABOi group and 83.0%, 81.3%, and 80.0% in ABOc group, with no significant differences (P=0.11).

Conclusions: RTx-based tailored (optional IVIG + splenectomy) desensitization protocol for ABOi LDLT was feasible and acceptable.
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http://dx.doi.org/10.21037/atm-20-4703DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859775PMC
January 2021

Outcomes after Liver Transplantation in Korea: Incidence and Risk Factors from Korean Transplantation Registry.

Clin Mol Hepatol 2021 Feb 2. Epub 2021 Feb 2.

Department of Surgery, Yonsei University College of Medicine, Seoul, South 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±SD 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.

Conclusions: 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
February 2021

2D shear wave elastography is better than transient elastography in predicting post-hepatectomy complication after resection.

Eur Radiol 2021 Jan 18. Epub 2021 Jan 18.

Department of Radiology, Chung-Ang University Hospital, Seoul, South Korea.

Objectives: Both transient elastography (TE) and 2D shear wave elastography (SWE) are accurate methods to evaluate liver fibrosis. We aimed to evaluate the diagnostic performance of 2D-SWE in predicting post-hepatectomy complication and to compare it with TE.

Methods: We prospectively enrolled 125 patients with liver tumors. Liver stiffness (LS) (kilopascal [kPa]) was measured using both TE and 2D-SWE before surgery. All post-operative complication was evaluated using the comprehensive complication index (CCI), and CCI ≥ 26.2 was defined as severe complication. Logistic regression analysis was performed to identify predictive factors for severe complication. Receiver operating characteristic analysis was used to evaluate the diagnostic performance of TE/2D-SWE in detecting liver fibrosis and severe complication.

Results: Severe complication developed in 18 patients. The median LS in patients with severe complication was significantly higher for both 2D-SWE (11.4 kPa vs. 7.0 kPa, p < 0.001) and TE (8.9 kPa vs. 6.2 kPa, p = 0.009). LS obtained from 2D-SWE was a significant factor correlated with severe complication (odds ratio: 1.27 per kPa [1.10-1.46], p = 0.001). The diagnostic performance of 2D-SWE was significantly higher than that of TE in detecting both ≥F3 (p = 0.024) and F4 (p = 0.048). The area under the curve of 2D-SWE to predict severe complication was 0.854, significantly higher than 0.692 of TE (p = 0.004). The optimal cut-off LS from 2D-SWE to predict severe complication was 8.6 kPa, with sensitivity of 88.9% (16/18) and specificity of 73.8% (79/107).

Conclusion: LS obtained from 2D-SWE was a significant predictive factor for severe complication, and 2D-SWE showed significantly a better diagnostic performance than TE in detecting liver fibrosis and severe complication.

Key Points: • The diagnostic performance of 2D-SWE was significantly higher than that of TE in detecting both ≥ F3 (AUC: 0.853 vs. 0.779, p = 0.024) and F4 (AUC: 0.929 vs. 0.872, p = 0.048). • Liver stiffness value obtained from 2D-SWE was a significant factor correlated with the development of severe complication defined as CCI ≥ 26.2 after hepatic resection for liver tumors (odds ratio: 1.27 per kPa [1.10-1.46], p = 0.001). • 2D-SWE provided significantly a better diagnostic performance in predicting severe complication after hepatic resection than TE (AUC for 2D-SWE: 0.853 vs. AUC for TE: 0.692, p = 0.004).
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http://dx.doi.org/10.1007/s00330-020-07662-3DOI Listing
January 2021

Short-term therapy with anti-ICAM-1 monoclonal antibody induced long-term liver allograft survival in nonhuman primates.

Am J Transplant 2021 Jan 10. Epub 2021 Jan 10.

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

Tolerance induction remains challenging following liver transplantation and the long-term use of immunosuppressants, especially calcineurin inhibitors, leads to serious complications. We aimed to test an alternative immunosuppressant, a chimeric anti-ICAM-1 monoclonal antibody, MD-3, for improving the outcomes of liver transplantation. We used a rhesus macaque liver transplantation model and monkeys were divided into three groups: no immunosuppression (n = 2), conventional immunosuppression (n = 4), and MD-3 (n = 5). Without immunosuppression, liver allografts failed within a week by acute rejection. Sixteen-week-long conventional immunosuppression that consisted of prednisolone, tacrolimus, and an mTOR inhibitor prolonged liver allograft survival; however, recipients died of acute T cell-mediated rejection (day 52), chronic rejection (days 62 and 66), or adverse effects of mTOR inhibitor (day 32). In contrast, 12-week-long MD-3 therapy with transient conventional immunosuppression in the MD-3 group significantly prolonged the survival of liver allograft recipients (5, 96, 216, 412, 730 days; p = .0483). MD-3 effectively suppressed intragraft inflammatory cell infiltration, anti-donor T cell responses, and donor-specific antibody with intact anti-cytomegalovirus antibody responses. However, this regimen ended in chronic rejection. In conclusion, short-term therapy with MD-3 markedly improved liver allograft survival to 2 years without maintenance of immunosuppressant. MD-3 is therefore a promising immune-modulating agent for liver transplantation.
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http://dx.doi.org/10.1111/ajt.16486DOI Listing
January 2021

Complications of polytetrafluoroethylene graft use in middle hepatic vein reconstruction in living donor liver transplantation: a retrospective, single-centre, long-term, real-world experience.

Transpl Int 2021 Mar 21;34(3):455-464. Epub 2021 Jan 21.

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

In living donor liver transplantation (LDLT) of the right lobe, polytetrafluoroethylene (PTFE) grafts may be used for anterior drainage. This study aimed to determine the risk factors of PTFE graft-associated complications. Data from patients who underwent LDLT of the right lobe with middle hepatic vein reconstruction using PTFE grafts between January 2005 and December 2012 were retrospectively reviewed. Among 360 patients, PTFE graft-associated complications occurred in 17 patients (group B) (4.7%); recipients without these complications comprised group A (95.3%). The 1-, 6- and 12-month patency rates were significantly lower in group B (P < 0.001, P = 0.002 and P = 0.007). In group B, eight patients (47.1%) required surgical intervention, three patients (17.6%) suffered from infectious complications, and 14 patients (82.4%) experienced PTFE graft migration into the adjacent organs, namely the common bile duct (n = 3, 17.6%), stomach (n = 1, 5.9%), duodenum (n = 5, 29.4%) and jejunum (n = 5, 29.4%). The proportion of recipients who underwent hepaticojejunostomy, had abdominal adhesions and received interventions in/around the liver after LDLT was higher in group B (P < 0.001). Although the incidence of PTFE graft-associated complication is low, close long-term follow-up is needed, especially in patients with risk factors.
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http://dx.doi.org/10.1111/tri.13807DOI Listing
March 2021

Bridging and downstaging role of trans-arterial radio-embolization for expected small remnant volume before liver resection for hepatocellular carcinoma.

Ann Hepatobiliary Pancreat Surg 2020 Nov;24(4):421-430

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

Backgrounds/aims: To evaluate our initial experience of bridging role of trans-arterial radio-embolization (TARE) before major hepatectomy for hepatocellular carcinoma (HCC) in risky patients with small expected remnant liver volume (ERLV).

Methods: We reviewed the data of patients with HCC who underwent major hepatectomy after TARE during the period between March and December 2017. Patients included had uni-lobar large HCC (>5 cm) requiring major hepatectomy with small ERLV.

Results: Five patients were included in our study. All patients were Child Pugh class A. A single session of TARE was applied in all patients. None developed any adverse events related to irradiation. The mean tumor size at baseline was 8.4 cm and 6.1 cm after TARE (=0.077). The mean % of tumor shrinkage was 24.5%. ERLV improved from 354.6 ml at baseline to 500.8 ml after TARE (=0.012). ERLV percentage improved from 27.2% at baseline to 38.1% after TARE (=0.004). The mean % of ERLV was 39.5%. The mean interval time between TARE and resection was 99.6 days. Four patients (80%) underwent right hemi-hepatectomy and one patient (20%) underwent extended right hemi-hepatectomy. The mean operation time was 151 minutes, and mean blood loss was 56 ml. The mean hospital stay was 13.8 days, and one patient (20%) developed postoperative morbidity. After a mean follow-up of 15 months, all patients were alive with no recurrence.

Conclusions: Yttrium-90 TARE can play a bridging role before major hepatectomy for borderline resectable HCC in risky patients with small ERLV.
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http://dx.doi.org/10.14701/ahbps.2020.24.4.421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691198PMC
November 2020

Sirolimus and MMF are insufficient immunosuppressants for regulation of the proliferation of CD133+EpCAM+ cell populations in HCC cell lines.

Biomed Rep 2020 Dec 20;13(6):69. Epub 2020 Oct 20.

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

Studies on effective immunosuppressive strategies for the management of patients undergoing a liver transplantation (LT) due to hepatocellular carcinoma (HCC) are limited. In the present study, immunosuppressive candidates predicted to exhibit beneficial immunosuppressive and tumor-suppressive effects in patients with HCC were assessed using Huh7 and HEP3B HCC cells, which have high proportions of CD133+EpCAM+ cancer stem cell (CSC) populations. The immunosuppressants assessed were sirolimus, tacrolimus, cyclosporine A and mycophenolate mofetil (MMF), and their activities were assessed on CSCs. Sirolimus and MMF reduced the proliferation of Huh7 and HEP3B cells; however, the proportion of CD133+EpCAM+ was notably increased in treated Huh7 cells. Sirolimus treatment alone resulted in G0-G1 cell cycle arrest at all doses in all Huh7 and CD133-EpCAM- populations; however, CD133+EpCAM+ populations showed only slight G1 arrest at higher doses only. In contrast, S-phase arrest was induced at all doses in the Huh7, CD133-EpCAM- and CD133+EpCAM+ populations by MMF. Sirolimus and MMF effectively reduced the proliferation of Huh7 and HEP3B cells, but did not exert a notable effect on the CD133+EpCAM+ cells. Therefore, therapeutic strategies utilizing Sirolimus and MMF should be further studied for regulation of CSC populations in order to reduce HCC recurrence rates.
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http://dx.doi.org/10.3892/br.2020.1376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657084PMC
December 2020

Fatty-acid-induced FABP5/HIF-1 reprograms lipid metabolism and enhances the proliferation of liver cancer cells.

Commun Biol 2020 Oct 30;3(1):638. Epub 2020 Oct 30.

Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, 03080, South Korea.

Hypoxia-inducible factor-1 alpha (HIF-1α) is a transcription factor essential for cancer cell survival. The reprogramming of lipid metabolism has emerged as a hallmark of cancer, yet the relevance of HIF-1α to this process remains elusive. In this study, we profile HIF-1α-interacting proteins using proteomics analysis and identify fatty acid-binding protein 5 (FABP5) as a critical HIF-1α-binding partner. In hepatocellular carcinoma (HCC) tissues, both FABP5 and HIF-1α are upregulated, and their expression levels are associated with poor prognosis. FABP5 enhances HIF-1α activity by promoting HIF-1α synthesis while disrupting FIH/HIF-1α interaction at the same time. Oleic-acid treatment activates the FABP5/HIF-1α axis, thereby promoting lipid accumulation and cell proliferation in HCC cells. Our results indicate that fatty-acid-induced FABP5 upregulation drives HCC progression through HIF-1-driven lipid metabolism reprogramming.
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http://dx.doi.org/10.1038/s42003-020-01367-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599230PMC
October 2020

Outcomes of Pediatric Liver Transplantation in Korea Using Two National Registries.

J Clin Med 2020 Oct 26;9(11). Epub 2020 Oct 26.

Department of Surgery, Seoul National University College of Medicine, Seoul 08826, Korea.

Background: This retrospective study aimed to evaluate overall survival and the risk factors for mortality among Korean pediatric liver transplantation (LT) patients using data from two national registries: the Korean Network Organ Sharing (KONOS) of the Korea Centers for Disease Control and Prevention and the Korean Organ Transplantation Registry (KOTRY).

Methods: Prospectively collected data of 755 pediatric patients who underwent primary LT (KONOS, February 2000 to December 2015; KOTRY, May 2014 to December 2017) were retrospectively reviewed.

Results: The 1-, 5-, 10-, and 15-year survival rates were 90.6%, 86.7%, 85.8%, and 85.5%, respectively, in KONOS, and the 1-month, 3-month, 1-year, and 2-year survival rates were 92.1%, 89.4%, 89.4%, and 87.2%, respectively, in KOTRY. There was no significant difference in survival between the two registries. Multivariate analysis identified that body weight ≥6 kg ( <0.001), biliary atresia as underlying liver disease ( = 0.001), and high-volume center ( < 0.001) were associated with better survival according to the KONOS database, while hepatic artery complication ( < 0.001) was associated with poorer overall survival rates according to the KOTRY database.

Conclusion: Long-term pediatric patient survival after LT was satisfactory in this Korean national registry analysis. However, children with risk factors for poor outcomes should be carefully managed after LT.
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http://dx.doi.org/10.3390/jcm9113435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7694033PMC
October 2020

Influence of Large Grafts Weighing ≥ 1000 g on Outcome of Pure Laparoscopic Donor Right Hepatectomy.

J Gastrointest Surg 2020 Oct 26. Epub 2020 Oct 26.

Department of Surgery, Seoul National University College of Medicine, 101 Daehakro, Jongrogu, Seoul, 03080, Korea.

Background: Depending on a transplant center's level of experience, utilization of pure laparoscopic donor right hepatectomy (PLDRH) may be limited due to graft size or anatomical variations. Here, we aimed to evaluate the influence of large hepatic grafts (≥ 1000 g) when performing PLDRH in both donors and recipients of such grafts.

Methods: Medical records of living donors who underwent either PLDRH from November 2015 to August 2019 or open conventional donor right hepatectomy (CDRH) from January 2010 to August 2019 and those of the graft recipients were retrospectively reviewed. Donors were separated into three groups: PLDRH graft ≥ 1000 g (n = 10; study group), PLDRH graft < 1000 g (n = 280; control-I group), and CDRH graft ≥ 1000 g (n = 24; control-II group).

Results: Total operative duration (P = 0.017) and warm ischemia time (P < 0.001) were significantly longer in the study than in the control-I and control-II groups, respectively. ΔAlanine aminotransferase% was significantly lower in the study than in the control-I group (P = 0.001). There was no significant difference in minor complication incidence between the study and control-I (P = 0.068) and control-II (P = 0.618) donors. There were no major complications in the study and control-II donors, whereas six control-I donors (2.1%) experienced a major complication (P = 1.000). Length of hospitalization was significantly shorter in the study than in the control-II group (P < 0.001). There was no significant difference in early and late major complication incidence for recipients between the study and control-I and control-II groups.

Conclusions: PLDRH for grafts weighing ≥ 1000 g appears to be safe and feasible when performed by experienced surgeons in a well-equipped center.
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http://dx.doi.org/10.1007/s11605-020-04837-7DOI Listing
October 2020

Magnetic Resonance Elastography Versus Transient Elastography in the Prediction of Complications After Resection for Hepatocellular Carcinoma.

Ann Surg 2020 Oct 19. Epub 2020 Oct 19.

Division of Biostatistics, Medical Research Collaborating Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.

Objective: To compare the performances of magnetic resonance elastography (MRE) and transient elastography (TE) for predicting severe complications after hepatic resection (HR) in patients with hepatocellular carcinoma (HCC).

Summary Background Data: Liver stiffness measurement (LSM) may have the potential to predict outcomes after HR in HCC patients.

Methods: Consecutive patients who underwent HR for HCC between 2017 and 2019 were retrospectively enrolled. Before HR, LSM was performed in all patients using both MRE and TE. All postoperative complications were assessed using the comprehensive complication index (CCI). Severe postoperative complications were defined as a CCI≥26.2. The performances of MRE and TE for predicting high CCI and diagnosing liver fibrosis were compared using the area under the receiver-operating-characteristic curve (AUROC). Uni-/multivariable logistic regression analyses were used to identify factors associated with high CCI.

Results: Among the 208 enrolled patients, 28 patients (13.5%) had high CCI. For detecting high CCI, MRE had an AUROC of 0.874 (95% confidence interval [CI], 0.821-0.916), which was significantly higher than the AUROC of TE (0.756; 95% CI, 0.692-0.813)(P = 0.020). MRE outperformed TE in detecting fibrosis of ≥F2 (AUROC: 0.935 vs. 0.767; P = 0.008), ≥F3 (AUROC: 0.902 vs. 0.774; P = 0.001) and F4 (AUROC: 0.916 vs. 0.767; P<0.001). LSM by MRE was independently associated with high CCI (odds ratio, 4.207 per kPa; 95% CI, 1.862-9.504; P<0.001), whereas LSM by TE was not.

Conclusions: MRE better predicted severe postoperative complications than TE in HCC patients who underwent HR. LSM by MRE was independently associated with high CCI after HR.
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http://dx.doi.org/10.1097/SLA.0000000000004576DOI Listing
October 2020

Sirolimus Prolongs Survival after Living Donor Liver Transplantation for Hepatocellular Carcinoma Beyond Milan Criteria: A Prospective, Randomised, Open-Label, Multicentre Phase 2 Trial.

J Clin Med 2020 Oct 12;9(10). Epub 2020 Oct 12.

Department of Surgery, Seoul National University Hospital, 101 Daehak-no, Jongno-gu, Seoul 110-744, Korea.

Sirolimus (SRL) has been reported to benefit patients undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC). This study aimed to compare SRL with tacrolimus (TAC) in living-donor LT (LDLT) recipients beyond the Milan criteria. This study was initially designed to enrol 45 recipients who underwent LDLT for HCC beyond the Milan criteria. At 1 month after LT, the patients were randomly assigned to either SRL or TAC-based treatment, with both groups receiving mycophenolate mofetil. The primary outcome was three-year recurrence-free survival (RFS) and the secondary outcome was overall survival (OS). A total of 42 patients completed the study. HCC recurrence occurred in 8 of 22 (36.4%) patients in the SRL group and in 5 of 22 (25%) patients in the TAC group. No differences in RFS and OS were found between the two groups in simple comparison. The type of immunosuppressant remained a nonsignificant factor for recurrence in multivariate analysis; however, SRL significantly prolonged OS (TAC hazard ratio: 15 [1.3-172.85], = 0.03) after adjusting for alpha-fetoprotein and positron emission tomography standardised uptake value ratio (tumour/background liver). In conclusion, SRL does not decrease HCC recurrence but prolongs OS after LDLT for HCC beyond the Milan criteria.
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http://dx.doi.org/10.3390/jcm9103264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600292PMC
October 2020

Association between spleen volume and the post-hepatectomy liver failure and overall survival of patients with hepatocellular carcinoma after resection.

Eur Radiol 2021 Apr 7;31(4):2461-2471. Epub 2020 Oct 7.

Department of Pathology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.

Objectives: Post-hepatectomy liver failure (PHLF) can occur as a major complication after hepatic resection (HR) in patients with hepatocellular carcinoma (HCC) and negatively affects the prognosis. We aimed to retrospectively assess whether the spleen volume (SV) measured from preoperative CT images would be associated with the development of PHLF and overall survival (OS) after HR in patients with HCC.

Methods: We enrolled 317 consecutive patients with very early/early stage HCC who underwent a preoperative CT and HR between January 2010 and December 2016. The SV was obtained from preoperative CT images using semi-automated volumetric software and was divided by body surface area to yield SV. Receiver operating characteristic (ROC) curves and logistic regression analyses were performed to identify factors affecting the development of PHLF. The Cox proportional hazard model was used to identify prognostic factors for OS.

Results: PHLF was observed in 72 patients (22.7% [72/317]). SV was associated with the development of PHLF (odds ratio, 2.321; 95% CI, 1.347-4.001; p = 0.002) with the area under the ROC curve of 0.663 using the cutoff value of 107.5 cm (p < 0.001). SV was also an influencing factor for OS (hazard ratio, 3.935; 95% CI 1.520-10.184; p = 0.005), with the optimal cutoff of 146 cm. The 5-year OS rate was higher in 245 patients with a SV ≤ 146 cm than in 72 patients with a SV > 146 cm (95.0% vs. 78.7%, p < 0.001).

Conclusions: In patients with HCC, a larger SV was associated with a higher rate of PHLF and worse OS after HR. The SV may be useful in selecting good surgical candidates.

Key Points: • A significantly higher spleen volume divided by body surface area was observed in patients who experienced post-hepatectomy liver failure than in patients who did not (148 cm vs. 112 cm, p < 0.001). • The area under the receiver operating characteristic curve of spleen volume divided by body surface area to predict the development of post-hepatectomy liver failure was 0.663 (p < 0.001). • Spleen volume divided by body surface area was a significant influencing factor for overall survival (hazard ratio, 3.935; 95% CI, 1.520-10.184; p < 0.001), with the optimal cutoff of 146 cm.
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http://dx.doi.org/10.1007/s00330-020-07313-7DOI Listing
April 2021

Novel Model to Predict HCC Recurrence after Liver Transplantation Obtained Using Deep Learning: A Multicenter Study.

Cancers (Basel) 2020 Sep 29;12(10). Epub 2020 Sep 29.

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

Several models have been developed using conventional regression approaches to extend the criteria for liver transplantation (LT) in hepatocellular carcinoma (HCC) beyond the Milan criteria. We aimed to develop a novel model to predict tumor recurrence after LT by adopting artificial intelligence (MoRAL-AI). This study included 563 patients who underwent LT for HCC at three large LT centers in Korea. Derivation ( = 349) and validation ( = 214) cohorts were independently established. The primary outcome was time-to-recurrence after LT. A MoRAL-AI was derived from the derivation cohort with a residual block-based deep neural network. The median follow-up duration was 74.7 months (interquartile-range, 18.5-107.4); 204 patients (36.2%) had HCC beyond the Milan criteria. The optimal model consisted of seven layers including two residual blocks. In the validation cohort, the MoRAL-AI showed significantly better discrimination function (c-index = 0.75) than the Milan (c-index = 0.64), MoRAL (c-index = 0.69), University of California San Francisco (c-index = 0.62), up-to-seven (c-index = 0.50), and Kyoto (c-index = 0.50) criteria (all 0.001). The largest weighted parameter in the MoRAL-AI was tumor diameter, followed by alpha-fetoprotein, age, and protein induced by vitamin K absence-II. The MoRAL-AI had better predictability of tumor recurrence after LT than conventional models. The MoRAL-AI can also evolve with further data.
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http://dx.doi.org/10.3390/cancers12102791DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7650768PMC
September 2020

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

J Clin Med 2020 Sep 8;9(9). Epub 2020 Sep 8.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 13557, Korea.

Cytochrome P450 () polymorphism influences tacrolimus metabolism, but its effect on the drug pharmacokinetics in liver transplant recipients switched to once-daily extended-release formulation remains unknown. The aim of this study is to analyze the effect of polymorphism on liver function after once-daily tacrolimus conversion in liver transplant patients. A prospective open-label study included 60 stable liver transplant recipients who underwent 1:1 conversion from twice-daily tacrolimus to once-daily tacrolimus. All participants were genotyped for polymorphism. The study was registered at ClinicalTrials.gov (NCT02882113). Twenty-eight patients were enrolled in the expressor group and 32 in the non-expressor group. Although there was no statistical difference, incidence of liver dysfunction was higher in the expressor group than in the non-expressor group when converted to once-daily extended-release tacrolimus ( = 0.088). No biopsy-proven acute rejection, graft failure, and mortality were observed in either group. The decrease in dose-adjusted trough level (-42.9% vs. -26.1%) and dose/kg-adjusted trough level of tacrolimus (-40.0% vs. -23.7%) was significantly greater in the expressor group than in the non-expressors after the conversion. A pharmacokinetic analysis was performed in 10 patients and tacrolimus absorption in the non-expressor group was slower than in the expressor group. In line with this observation, the area under the curve for once-daily tacrolimus correlated with trough level (Cmin) in the non-expressors and peak concentration (Cmax) in the expressors. genotyping in liver transplant recipients leads to prediction of pharmacokinetics after switching from a twice-daily regimen to a once-daily dosage form, which makes it possible to establish an appropriate dose of tacrolimus.
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http://dx.doi.org/10.3390/jcm9092897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7563461PMC
September 2020

Dextroplantation of Left Liver Graft in Infants.

Liver Transpl 2021 02 20;27(2):222-230. Epub 2020 Oct 20.

Division of HBP Surgery, Departments of Surgery, Seoul National University College of Medicine, Seoul, South Korea.

The position of the left side liver graft is important, and it could lead to complications of the hepatic vein (HV) and portal vein (PV), especially in a small child using a variant left lateral section (vLLS) graft. The purpose of this study was to evaluate the outcome of a novel technique for the implantation of a vLLS graft to the right side (dextroplantation) in infants. For 3 years, 10 consecutive infants underwent dextroplantation using a vLLS graft (group D). The graft was implanted to the right side of the recipient after 90° counterclockwise rotation; the left HV graft was anastomosed to inferior vena cava using the extended right and middle HV stump, and PV was reconstructed using oblique anastomosis without angulation. Surgical outcomes were compared with the historical control group (n = 17, group C) who underwent conventional liver transplantation using a vLLS during infancy. Group D recipients were smaller than group C (body weight <6 kg: 50.0% versus 11.8%; P = 0.03). The rate of graft-to-recipient weight ratio >4% was higher in group D (60.0%) than C (11.8%; P = 0.01). Surgical drains were removed earlier in group D than in group C (15 versus 18 postoperative days [PODs]; P = 0.048). Each group had 1 PV complication (10.0% versus 5.9%); no HV complication occurred in group D, but 3 HV complications (17.6%) occurred in group C (P > 0.05). Hospital stay was shorter in group D than in group C (20 versus 31 PODs; P = 0.02). Dextroplantation of a vLLS graft, even a large-for-size one, was successful in small infants without compromising venous outcomes, compared with conventional vLLS transplantation. We could remove the surgical drains earlier and reduce hospital stays in cases of dextroplantation.
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http://dx.doi.org/10.1002/lt.25883DOI Listing
February 2021

No touch isolation technique for the prevention of postoperative recurrence of hepatocellular carcinoma after liver transplantation-combined with trans-arterial radioembolization.

Surg Oncol 2020 Dec 28;35:189-190. Epub 2020 Aug 28.

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

Introduction: Transarterial radioembolization (TARE) is recently emerging treatment modality using radiation from Yttrium-90 through the transarterial approach. It usually is used in the intermediate stage and unresectable hepatocellular carcinoma (HCC). No touch isolation technique is a way to prevent the spread of tumors by pre-ligating the vessels around the tumor with minimal touch during surgery. We hoped that if we were to use these techniques, we would be able to control all viable tumors before liver transplantation. Then we could get better outcomes even in the advanced hepatocellular carcinoma patients.

Methods: We performed living donor liver transplantation using no touch isolation technique in the patients who had multinodular hepatocellular carcinoma and extremely high AFP, PIVKA-II level after TARE and conventional TACE.

Results: 36 years old female patient had liver cirrhosis with hepatitis B virus infection and multiple hepatocellular carcinoma in both lobes. Hepatologist decided to do TARE and additional conventional TACE for viable tumors. After that treatment, AFP and PIVKA-II level were dramatically decreased, we decided to proceed of living donor liver transplantation because the patient's treatment response was extremely good.

Conclusions: No touch isolation technique combined with TARE for recipient hepatectomy might be helpful in advanced stage hepatocellular carcinoma patients.
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http://dx.doi.org/10.1016/j.suronc.2020.08.024DOI Listing
December 2020

New-onset diabetes after adult liver transplantation in the Korean Organ Transplantation Registry (KOTRY) study.

Hepatobiliary Surg Nutr 2020 Aug;9(4):425-439

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

Background: New-onset diabetes after transplantation (NODAT) is a serious complication following liver transplantation (LT). The present study aimed to investigate the incidence of and risk factors for NODAT using the Korean Organ Transplantation Registry (KOTRY) database.

Methods: Patients with history of pediatric transplantation (age ≤18 years), re-transplantation, multi-organ transplantation, or pre-existing diabetes mellitus were excluded. A total of 1,919 non-diabetic adult patients who underwent a primary LT between May 2014 and December 2017 were included. Risk factors were identified using Cox regression analysis.

Results: NODAT occurred in 19.7% (n=377) of adult liver transplant recipients. Multivariate analysis showed steroid use, increased age, and high body mass index (BMI) in recipients, and implantation of a left-side liver graft was closely associated with NODAT in adult LT. In living donor liver transplant (LDLT) patients (n=1,473), open donor hepatectomy in the living donors, steroid use, small for size liver graft (graft to recipient weight ratio ≤0.8), increased age, and high BMI in the recipient were predictive factors for NODAT. The use of antimetabolite and basiliximab induction reduced the incidence of NODAT in adult LT and in adult LDLT.

Conclusions: Basiliximab induction, early steroid withdrawal, and antimetabolite therapy may prevent NODAT after adult LT. High BMI or advanced age in liver recipients, open donor hepatectomy in living donors, and small size liver graft can predict the occurrence of NODAT after adult LT or LDLT.
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http://dx.doi.org/10.21037/hbsn.2019.10.29DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7423540PMC
August 2020

Pure Laparoscopic Donor Hepatectomy: A Multicenter Experience.

Liver Transpl 2021 01 5;27(1):67-76. Epub 2020 Sep 5.

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

According to recent international consensus conferences, pure laparoscopic donor hepatectomy (PLDH), particularly right and left hepatectomies, is not yet considered a standard practice because studies remain limited. Thus, we present the outcomes of more than 500 PLDH patients, mostly receiving a right hepatectomy. To our knowledge, this is the largest study to date on PLDH. Data from all living liver donors who underwent PLDH at 5 centers in Korea until June 2018 were retrospectively analyzed. The outcomes of both donors and recipients were included. Pearson correlation analysis was used to explore the relationship between the duration of surgery and cumulative experience at each center, which reflects the learning curve. Overall, 545 PLDH cases were analyzed, including 481 right hepatectomies, 25 left hepatectomies, and 39 left lateral sectionectomies (LLS). The open conversion was necessary for 10 (1.8%) donors, and none of the donors died or experienced irreversible disability. Notably, there were 25 (4.6%) patients with major complications (higher than Clavien-Dindo grade 3). All centers except one showed a significant decrease in surgery duration as the number of cases accumulated. Regarding recipient outcomes, there were 110 cases (20.2%) of early major complications and 177 cases (32.5%) of late major complications. This study shows the early and late postoperative outcomes of 545 donors and corresponding recipients, including 481 right hepatectomies and 25 left hepatectomies, from 5 experienced centers. Although the results are comparable to those of previously reported open donor hepatectomy series, further studies are needed to consider PLDH a new standard practice.
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http://dx.doi.org/10.1002/lt.25848DOI Listing
January 2021

Techniques for overcoming atretic changes of the portal vein in living donor liver transplantation.

Hepatobiliary Pancreat Dis Int 2020 Aug 30;19(4):311-317. Epub 2020 Jun 30.

Department of Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Electronic address:

Background: Spontaneous diversion of the portal flow through collateral vessels into the systemic circulation is frequently observed in liver transplant recipients with severe portal hypertension. This induces main portal vein atretic change and modifies flow into the collateral even after donor graft implantation. These atretic changes make liver transplantation challenging. In this article we described several methods for overcoming this challenge by appropriate surgical techniques.

Methods: Three anastomotic techniques for living donor liver transplantation were performed in patients with atretic changes in the portal vein.

Results: The three techniques were (1) venoplasty to widen the diameter by using the recipient's portal vein, and the diameter of the recipient's portal vein was enlarged using their own portal vein stump patch; (2) conduit with cryopreserved vessels, and we dissected around the superior mesenteric vein and splenic vein junction and a conduit was built using the cryopreserved vessels; and (3) left gastric varix to portal vein anastomosis, if the recipients had large gastric varix and variceal wall was sufficiently thick for anastomosis.

Conclusions: Selection of optimal methods for portal vein anastomosis is essential in patients with atrophic change on the portal vein. If these methods are used aptly, they can be considered as favorable methods for overcoming each situation.
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http://dx.doi.org/10.1016/j.hbpd.2020.06.016DOI Listing
August 2020

Parietal Peritoneum as a Novel Substitute for Middle Hepatic Vein Reconstruction During Living Donor Liver Transplantation.

Transplantation 2020 Jun 15. Epub 2020 Jun 15.

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

Background: Although autologous, cryopreserved, or artificial vascular grafts can be used as interpositional vascular substitutes for MHV reconstruction during LDLT, they are not always available, are limited in size and length, and are associated with risks of infection. This study aimed to evaluate the parietal peritoneum as a novel substitute for middle hepatic vein (MHV) reconstruction during living donor liver transplantation (LDLT).

Methods: Prospectively collected data of 15 patients who underwent LDLT using the right liver with reconstruction of MHV using the recipients' own parietal peritoneum graft were retrospectively reviewed.

Results: The 1-, 2-, 3-, and 5-month patency rates were 57.1%, 57.1%, 57.1%, and 28.6%, respectively. Among the 15 cases assessed, the most recent 6 cases showed patent graft flow until discharge with 1-, 2-, 3-, and 5-month patency rates of 80.0%, 80.0%, 80.0%, and 20.0%, respectively. All patients survived with tolerable liver function tests. There were no significant congestion-related problems, except for 1 patient who experienced MHV thrombosis requiring aspiration thrombectomy and stent insertion. There were no infection-related complications. All patients survived to the final follow-up, with a minimum follow-up duration of 8 months. When comparing the latter 6 cases of peritoneal grafts and the recent 28 cases of conventional polytetrafluorethylene (PTFE) graft, the overall patency rate of the PTFE group was higher (P = 0.002). There were no major differences other than long-term patency rate.

Conclusions: Parietal peritoneum may be a novel autologous substitute for MHV reconstruction during LDLT.
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http://dx.doi.org/10.1097/TP.0000000000003349DOI Listing
June 2020

Impact of PNPLA3 (rs738409-G) polymorphism on post-transplant outcomes after liver transplantation for alcohol-related liver disease.

Clin Transplant 2020 09 28;34(9):e14011. Epub 2020 Jul 28.

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

Introduction: We aimed to evaluate the association between PNPLA3 polymorphism and post-liver transplantation (LT) outcomes related to alcohol relapse (AR).

Method: We retrospectively analyzed data from patients receiving LT for alcoholic liver disease (ALD) from 04/2014 to 12/2017. Liver-related clinical outcomes were assessed by the gamma-glutamyltransferase (GGT) level and alcohol-related liver failure (ARLF). Genotyping was performed using prospectively collected DNA samples in both donors and recipients.

Results: A total of 83 recipients were enrolled. Post-LT AR occurred in 31 patients (37.3%). Thirty-one patients (14 AR, 9 abstainers) showed elevated GGT levels, and 3 AR patients experienced ARLF. In the multivariate analysis, rs738409 G allele carrier and heavy drinking (HRAR score ≥ 4) were independent risk factors for elevated GGT levels (odds ratio [OR] = 8.69, P < .01; OR = 13.07, P = .01) and ARLF (OR = 4.52, P = .04; OR = 19.62, P = .03). Among 15 heavy AR patients, being an rs738409 G allele carrier was related to GGT elevation (P = .03) and ARLF (P = .04), but it was not related to GGT elevation in mild drinkers (n = 16) or abstainers (n = 52).

Conclusion: PNPLA3 polymorphism of the recipient genotype can independently affect the post-LT prognosis of LT patients for ALD, especially in heavy AR patients. Therefore, strong abstinence education is recommended in patients with this single nucleotide polymorphism.
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http://dx.doi.org/10.1111/ctr.14011DOI Listing
September 2020

Influence of Body Mass Index ≥30 on Pure Laparoscopic Donor Right Hepatectomy.

Ann Transplant 2020 Jun 2;25:e923094. Epub 2020 Jun 2.

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

BACKGROUND Pure laparoscopic donor right hepatectomy (PLDRH) for donors with obesity has not been previously investigated. This study aimed to investigate the influence of donor obesity (BMI ≥30 kg/m²) on and clinical outcomes after PLDRH. MATERIAL AND METHODS Records of all living donors who underwent PLDRH between November 2015 and May 2018 and open conventional donor right hepatectomy (CDRH) between January 2011 and October 2015 at Seoul National University Hospital were retrospectively reviewed. The donors were divided into 3 groups: PLDRH BMI ≥30, PLDRH BMI <30, and CDRH BMI ≥30. RESULTS Donors in the PLDRH BMI ≥30 group (n=7) were compared with those in the PLDRH BMI <30 (n=65; control 1) and CDRH BMI ≥30 (n=8; control 2) groups. Graft weight was significantly heavier in PLDRH BMI ≥30 than in control 1 (P=0.012). The lowest hemoglobin (Hb) value was higher (P=0.014) and ΔHb% was lower (P=0.005) in PLDRH BMI ≥30 than in control 1. Similarly, the lowest Hb value was higher (P=0.021) and ΔHb% was lower (P<0.001) in PLDRH BMI ≥30 than in control 2. The peak alanine aminotransferase (ALT) (P=0.029) and ΔALT% were higher in PLDRH BMI ≥30 than in control 2. No significant differences in hospital stay and postoperative complications were found between PLDRH BMI ≥3 and control 1, as well as between PLDRH BMI ≥3 and control 2. CONCLUSIONS This study revealed that PLDRH is feasible in donors with obesity.
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http://dx.doi.org/10.12659/AOT.923094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292238PMC
June 2020

Donor wound satisfaction after living-donor liver transplantation in the era of pure laparoscopic donor hepatectomy.

Surg Endosc 2020 May 19. Epub 2020 May 19.

Department of Surgery, Seoul National University College of Medicine, 28 Yongon-Dong, Chongno-gu, Seoul, 110-744, Korea.

Background: Donor safety and cosmetic outcome are the main concerns raised by most living-donors. Pure laparoscopic living-donor hepatectomy (PLLDH) can provide the balance between those concerns. No studies evaluated the donors' satisfaction after PLLDH. The aim of this study is to evaluate the donors' satisfaction after PLLDH compared with donors who underwent open approach.

Methods: We randomly assigned a questionnaire (Donor satisfaction questionnaire) to the donors, operated between 2011 and 2017, during their follow-up visits in the outpatient clinic. Donors who responded to the questionnaire were included in our study. Donors were divided into 3 groups: L group (conventional inverted L incision), M group (midline incision), and PL group (laparoscopic approach).

Results: 149 donors were included in our study. L group included 60 donors (40.3%), M group included 39 patients (26.2%), and PL group included 50 patients (33.5%). There were no significant differences between the groups regarding preoperative and perioperative outcomes apart from shorter operation time in PL group and higher wound infection in M group. Body image scale was significantly better in PL group (p = 0.001). Cosmetic scale was significantly higher in PL group (p = 0.001). Regarding self-confidence scale, it was significantly higher in PL group (p = 0.001). There was no significant difference between the groups regarding the sense of dullness or numbness on the scar (p = 0.113).

Conclusion: PLLDH is safe and feasible for living-donor hepatectomy. Donors operated by pure laparoscopic approach have better satisfaction scores compared to conventional open approach.
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http://dx.doi.org/10.1007/s00464-020-07640-2DOI Listing
May 2020

Clinical Significance of De Novo Malignancy After Liver Transplant: A Single-Center Study.

Transplant Proc 2021 Jan-Feb;53(1):200-206. Epub 2020 May 11.

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

Background: Several studies have reported that solid organ transplant recipients have a high risk for malignant tumors because the suppressed immune system fails in preventing malignant transformations. De novo malignancy after transplantation is the most common cause of death in the late period after liver transplant (LT). This study investigated the clinical significance of de novo malignancy after LT, and it is the largest study based in Korea to report long-term follow-up results associated with de novo malignancy after LT.

Methods: Data of 1793 adults who underwent LT in Seoul National University Hospital were retrospectively collected, and medical charts and data from the Ministry of Public Administration and Security were reviewed to examine the causes of death and de novo malignancy status. The Fisher exact test and Kaplan-Meier survival analysis were used to analyze the data.

Results: Of the 1793 recipients, 27 died of de novo malignancies. Of 875 hepatocellular carcinoma (HCC) patients, 12 died, and of 918 non-HCC patients, 15 died. De novo malignancy was the main cause of death at 5 years after LT but was not in the initial 5 years. In Korea the most common cancers that developed after LT were gastric cancer (21.4%) and lymphoma (14.3%). De novo HCC in non-HCC cases was found in 2 patients.

Conclusion: De novo malignancy is a key factor affecting long-term survival after LT. Therefore, regular screening and education are important for improving long-term survival and quality of life in these patients after LT.
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http://dx.doi.org/10.1016/j.transproceed.2020.02.148DOI Listing
May 2020

The Effect of Global Surgery Fellowship for Tertiary Hospital Professionals from Myanmar: Current Issues and Future Challenges.

J Surg Educ 2020 Sep - Oct;77(5):1169-1178. Epub 2020 May 7.

Department of Medical Education, Seoul National University College of Medicine, Seoul, Korea. Electronic address:

Objective: As the surgical burden of diseases grows higher than ever, the development of skilled surgeons and surgery teams is of fundamental importance. However, there is scarce evidence of the effectiveness of surgical training programs. Our study aims to evaluate the effectiveness of a global surgery fellowship program.

Design: In 2018, Myanmar subspecialty surgeons were trained for a 3-month in tertiary hospital of Korea. We evaluated the reactions, learning, and transfer of the 11 trainees using Kirkpatrick's Evaluation Model.

Setting: Myanmar and Korean tertiary hospital.

Participants: Eleven participants of fellowship from Myanmar.

Results: Participants' overall reaction scores were 4.45 ± 0.52 out of 5.00. Regarding overall competency, the trainees assessed themselves as at an "advanced beginner level" (3.63 ± 1.38 out of 10.00) at the beginning and at a "competent level" (5.40 ± 1.70 out of 10.00) after the training (p for difference = 0.014). The trainees stated that their transfer in clinical practice was between "quite applicable" and "I am very sure that I can do this" (3.39 ± 0.61 out of 4.00). Their transfer in education was second, ranked around "quite applicable" (3.21 ± 0.77 out of 4.00), and their transfer in research was last and ranked "applicable, but just a little" (2.81 ± 0.67 out of 4.00). However, in our online survey, native and foreign trainers had mixed opinions about the transfer of training and were not entirely confident in the trainees' competency. Trainees felt that there were multifactorial challenges for transfer and cited infrastructure, facilities, human resources, perioperative care, and financing.

Conclusions: Surgical trainees reported high-level satisfaction and increased knowledge after training. However, further onsite surgical experiences are necessary for a successful transfer to the real setting. Challenges for such transfers were multifactorial, and surgical care must be systemically strengthened.
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http://dx.doi.org/10.1016/j.jsurg.2020.03.013DOI Listing
May 2020