Publications by authors named "Kyung-Suk Suh"

340 Publications

Tumor volume measured using MR volumetry as a predictor of prognosis after surgical resection of single hepatocellular carcinoma.

Eur J Radiol 2021 Sep 20;144:109962. Epub 2021 Sep 20.

Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, South Korea.

Purpose: To evaluate the clinical value of tumor volume-measurement using magnetic resonance (MR) volumetry for predicting prognosis after surgical resection of single small-to-medium-sized hepatocellular carcinoma (HCC) (≤5cm).

Method: This retrospective study included 162 consecutive patients who underwent preoperative gadoxetic acid-enhanced MRI and subsequent surgical resection for single HCC (≤5cm). Tumor volume was measured at hepatobiliary phase of MR images using semi-automated three-dimensional volumetric software program. Recurrence-free survival (RFS) and overall survival (OS) were estimated using Kaplan-Meier method. The Cox-proportional-hazard-model was used to evaluate clinical, pathologic, and radiologic prognostic factors. A minimal p-value approach based on log-rank test statistics was used to obtain the optimal-cutoff tumor volume for predicting RFS and OS. Inter-examiner reproducibility of MR volumetric measurements was assessed using intraclass correlation coefficient (ICC) and coefficient of variance (CV).

Results: After a median follow-up of 84.4 months (range, 2.8-126.5), HCC recurrence occurred in 69 (42.6%) patients and twenty-four (14.8%) patients died with estimated 5-year OS of 90.8%. Larger tumor volume was significantly associated with poor RFS(P = 0.018) and poor OS(P = 0.005) in multivariate analysis. For predicting RFS and OS after surgery, the optimal-cutoff of tumor volume was set at 4.0 mL and 4.0 mL, respectively, with larger volume ≥4.0 mL was significantly associated with poor RFS (hazard ratio[HR], 1.84, P = 0.023) and poor OS (HR, 2.66, P = 0.033). Inter-examiner reproducibility of tumor volume-measurement using MR-volumetry showed ICC of 0.980 and CV of 3.9%.

Conclusions: Tumor volume-measurement using MR-volumetry is clinically feasible and reproducible, and can help predict RFS and OS after resection of single small-to-medium-sized HCC.
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http://dx.doi.org/10.1016/j.ejrad.2021.109962DOI Listing
September 2021

Different Risk Factors for Early and Late Recurrence After Curative Resection of Hepatocellular Carcinoma.

World J Surg 2021 Sep 17. Epub 2021 Sep 17.

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

Background: Factors of early and late recurrence after curative resection of hepatocellular carcinoma (HCC) may be different. The aim of this study was to identify clinical factors, including liver stiffness measurement (LSM), which are associated with HCC recurrence after curative resection.

Methods: Patients who underwent preoperative LSM and primary curative resection for HCC between October 2015 and May 2018 were retrospectively reviewed, with 1 year as the cut-off between early and late recurrence.

Results: Recurrence was observed in 42/149 (28.2%) patients over a median follow-up of 38.3 months (early recurrence: 10 [6.7%] patients; late recurrence: 32 [21.5%] patients). Multivariate analysis identified LSM (P = 0.026) and tumor size (P = 0.010) as the only factors that were significantly associated with recurrence-free survival. Compared with patients without recurrence, those with early recurrence had larger tumor size (P = 0.035) and those with late recurrence had higher LSM (P = 0.024). Receiver-operating characteristic analysis indicated that the optimal LSM cut-off value for predicting HCC recurrence was 7.4 kPa.

Conclusion: Tumor size was associated with early HCC recurrence after curative resection and LSM was associated with late recurrence. LSM cut-off of 7.4 kPa is recommended in predicting recurrence.
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http://dx.doi.org/10.1007/s00268-021-06308-9DOI Listing
September 2021

LigaSure versus monopolar cautery for recipient hepatectomy in liver transplantation: a propensity score-matched analysis.

Ann Transl Med 2021 Jul;9(13):1050

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

Background: Recipient hepatectomy during liver transplantation (LT) is one of the most challenging aspects of surgery due to the possibility of massive bleeding. This study aimed to compare and analyze the effectiveness between LigaSure and monopolar cautery in recipients.

Methods: We reviewed 187 recipients who underwent LT from March 2019 to June 2020. We compared the surgical outcomes of the 69 recipients who underwent recipient hepatectomy with LigaSure (LigaSure group) and 118 recipients who underwent with monopolar cautery. Propensity score matching (PSM) was performed using the nearest-neighbor method at a ratio of 1:1 based on 14 baseline characteristics and possible factors that influence postoperative bleeding.

Results: A total of 187 adult recipients were reviewed retrospectively. In the propensity score-matched analysis, The rates of bleeding and infectious complication were significantly lower in the LigaSure group than in the monopolar cautery group (3/69, 4.35% versus 13/69, 18.8%; P=0.015 and 1/69, 1.45% versus 9/69, 13.0%; P=0.017). The length of postoperative hospital stay was shorter in the LigaSure group (mean: 23.1±16.1 versus 39.6±58.2 days; P=0.024).

Conclusions: Recipient hepatectomy with LigaSure is associated with a short hospital stay due to low re-operation rates, postoperative bleeding, and secondary infection related to bleeding.
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http://dx.doi.org/10.21037/atm-21-1318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8339826PMC
July 2021

Impact of Model for End-Stage Liver Disease allocation system on outcomes of deceased donor liver transplantation: A single-center experience.

Ann Hepatobiliary Pancreat Surg 2021 Aug;25(3):336-341

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

Backgrounds/aims: From June of 2016, the Model for End-Stage Liver Disease (MELD)-based allocation system replaced the Child- Turcotte-Pugh (CTP) score-based system for organ allocation liver in Korea. The aim of this study was to analyze changes in outcomes and arising issues before and after the implementation of the MELD system.

Methods: From June 2014 to June 2018, 129 patients were selected from recipients who underwent deceased donor liver transplantation (DDLT) in Seoul National University Hospital. Pediatric cases were excluded. According to the allocation system, patients were divided into two groups (52 in the MELD group and 77 in the CTP group).

Results: MELD scores of the two groups differed significantly (37.8 ± 2.0 in the MELD group vs. 31.0 ± 8.2 in the CTP group; = 0.001). The etiology of patients was changed for liver transplantation. The proportion of alcoholic liver cirrhosis increased in the era of the MELD allocation system. However, proportions of hepatitis B related liver cirrhosis and hepatocellular carcinoma were decreased. Six-month mortality rate of the MELD group was 25.0%, which was higher than that (11.7%) of the CTP group ( = 0.022). The 90-day complication rate was significantly higher in the MELD group than in the CTP group (11.5% vs. 2.6%; = 0.040).

Conclusions: When the MELD allocation system was used to distribute livers to severely ill patients, it resulted in poorer outcomes after surgery and higher proportion of alcoholic cirrhosis. Thus, it is necessary to adjust the MELD allocation system so that outcomes after DDLT could be improved.
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http://dx.doi.org/10.14701/ahbps.2021.25.3.336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8382855PMC
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

Systems analysis identifies endothelin 1 axis blockade for enhancing the anti-tumor effect of multikinase inhibitor.

Cancer Gene Ther 2021 Aug 6. Epub 2021 Aug 6.

Laboratory for Systems Biology and Bio-inspired Engineering, Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Korea.

Multikinase inhibitors, such as sorafenib, are used for the treatment of advanced carcinomas but the response shows limited efficacy or varies a lot with patients. Here we adopted the systems approach combined with high-throughput data analysis to discover key mechanism embedded in the drug response. When analyzing the transcriptomic data from the Cancer Cell Line Encyclopedia (CCLE) database, endothelin 1 (EDN1) was enriched in cancer cells with low responsiveness to sorafenib. We found that the level of EDN1 is higher in the tissue and blood of hepatocellular carcinoma (HCC) patients showing poor response to sorafenib. In vitro experiment showed that EDN1 not only induces activation of angiogenic-promoting pathways in HCC cells but also stimulates proliferation and migration. Moreover, EDN1 is related with poor responsiveness to sorafenib by mitigating unfolded protein response (UPR), which was validated in both transcriptomic data analysis and in silico simulation. Finally, we found that endothelin receptor B (EDNRB) antagonists can enhance the efficacy of sorafenib in both HCC cells and xenograft mouse models. Our findings provide that EDN1 is a novel diagnostic marker for sorafenib responsiveness in HCC and a basis for testing macitentan, which is currently used for pulmonary artery hypertension, in combination with sorafenib in advanced HCC patients.
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http://dx.doi.org/10.1038/s41417-021-00373-xDOI Listing
August 2021

Pure laparoscopic living donor liver transplantation: Dreams come true.

Am J Transplant 2021 Jul 31. Epub 2021 Jul 31.

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

Minimally invasive approaches are increasingly being applied in surgeries and have recently been used in living donor hepatectomy. We have developed a safe and reproducible method for minimally invasive living donor liver transplantation, which consists of pure laparoscopic explant hepatectomy and pure laparoscopic implantation of the graft, which was inserted through a suprapubic incision. Pure laparoscopic explant hepatectomy without liver fragmentation was performed in a 60-year-old man with alcoholic liver cirrhosis and hepatocellular carcinoma. The explanted liver was retrieved through a suprapubic incision. A modified right liver graft, procured from his 24-year-old son using the pure laparoscopic method, was inserted through a suprapubic incision, and implantation was performed intracorporeally throughout the procedure. The time required to remove the liver was 369 min, and the total operative time was 960 min. No complications occurred during or after the surgery. The patient recovered well, and his hospital stay was of 11 days. Pure laparoscopic living donor liver transplantation from explant hepatectomy to implantation was performed successfully. It is a feasible procedure when performed by a highly experienced surgeon and transplantation team. Further studies with larger sample sizes are needed to confirm its safety and feasibility.
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http://dx.doi.org/10.1111/ajt.16782DOI Listing
July 2021

Shorter operation time and improved surgical outcomes in laparoscopic donor right hepatectomy compared with open donor right hepatectomy.

Surgery 2021 Jul 10. Epub 2021 Jul 10.

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

Background: Pure laparoscopic donor right hepatectomy is a complex procedure, and the safety and feasibility of this operation remain unclear. This study aimed to evaluate the clinical outcomes and learning curve of this operation performed by a single surgeon.

Methods: We retrospectively reviewed the initial 100 donors who underwent pure laparoscopic donor right hepatectomy or open donor right hepatectomy by a single surgeon from December 2012 to May 2019. Endpoints analyzed included intraoperative results, postoperative complications, and learning curve, which was evaluated using the cumulative sum method based on the operation time. We divided the pure laparoscopic donor right hepatectomy group into initial and recent groups based on the time point of overcoming the learning curve.

Results: The operative time was significantly shorter in the recent pure laparoscopic donor right hepatectomy group (n = 57; 181.0 ± 35.7 min) than in the open donor right hepatectomy (n = 50; 203.0 ± 37.3 min) and initial pure laparoscopic donor right hepatectomy (n = 43; 282.2 ± 59.2 min) groups (P < .001). Moreover, the length of hospital stay in the recent pure laparoscopic donor right hepatectomy group was significantly reduced compared to that in the open donor right hepatectomy group (7.7 ± 1.2 vs 5.8 ± 1.4; P < .001). The complication rate was reduced from 10% in the open donor right hepatectomy group and 8% in the initial pure laparoscopic donor right hepatectomy group to 2% in the recent pure laparoscopic donor right hepatectomy group.

Conclusion: As technology advances, the surgical outcomes of pure laparoscopic donor right hepatectomy are comparable and the operation time of pure laparoscopic donor right hepatectomy is superior to those of open donor hepatectomy.
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http://dx.doi.org/10.1016/j.surg.2021.06.005DOI Listing
July 2021

Gadoxetate-enhanced MRI Features of Proliferative Hepatocellular Carcinoma Are Prognostic after Surgery.

Radiology 2021 09 6;300(3):572-582. Epub 2021 Jul 6.

From the Departments of Radiology (H.J.K., D.H.L., J.K.H.) and Pathology (H.K., Y.J.H.), Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul 03080, Korea; Departments of Radiology (H.J.K., D.H.L., J.K.H.), Pathology (H.K., Y.J.H.), and Surgery (K.S.S.), Seoul National University College of Medicine, Seoul, Korea; and Department of Radiology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea (B.Y.H.).

Background Hepatocellular carcinomas (HCCs) are heterogeneous neoplasms, and the prognosis varies based on the subtype. Two broad molecular classes of HCC have been proposed: a proliferative and a nonproliferative class. Purpose To evaluate the gadoxetate-enhanced MRI findings of the proliferative class HCC and its prognostic significance after surgery. Materials and Methods This retrospective cohort study evaluated patients with surgically resected treatment-naive single HCC (≤5 cm) who underwent hepatic resection from January 2010 through February 2013 and preoperative gadoxetate-enhanced MRI. A Cox proportional hazards model was used to determine the predictive factors for overall survival (OS), intrahepatic distant recurrence, and extrahepatic metastasis (EM). The mean follow-up period was 75.5 months ± 30.2 (standard deviation). Multivariable logistic regression was performed to determine factors associated with proliferative class HCC. Results A total of 158 patients (mean age, 57 years ± 11; 128 men and 30 women) were evaluated. Forty-two of the 158 HCCs (26.6%) were proliferative class HCCs (17 macrotrabecular-massive HCCs, 14 keratin 19-positive HCCs, 10 scirrhous HCCs, and one sarcomatoid HCC). The proliferative class was associated with worse OS (hazard ratio [HR], 3.1; 95% CI: 1.5, 6.0; = .01) and higher rates of intrahepatic distant recurrence (HR, 1.83; 95% CI: 1.1, 2.9; = .01) and EM (HR, 9.97; 95% CI: 3.2, 31.4; < .001). Rim arterial phase hyperenhancement (APHE) at gadoxetate-enhanced MRI (odds ratio [OR], 6.35; 95% CI: 1.9, 21.7; = .01) and high serum α-fetoprotein (>100 ng/mL) (OR, 4.18; 95% CI: 1.64, 10.7; = .01) were independent predictors for proliferative HCC. The presence of rim APHE was associated with poor OS (HR, 2.4; 95% CI: 1.2, 4.9; = .02) and higher rates of EM (HR, 7.4; 95% CI: 2.5, 21.7; < .01). Conclusion The proliferative class of hepatocellular carcinoma (HCC) is an independent factor for poor overall survival with increased rates of intrahepatic and extrahepatic metastasis. Rim arterial phase hyperenhancement at gadoxetate-enhanced MRI may help to identify proliferative class HCC and predict poor overall survival and an increased incidence of extrahepatic metastasis. © RSNA, 2021 See also the editorial by Krinsky and Shanbhogue in this issue.
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http://dx.doi.org/10.1148/radiol.2021204352DOI Listing
September 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

Multicenter Propensity Score-Based Study of Laparoscopic Repeat Liver Resection for Hepatocellular Carcinoma: A Subgroup Analysis of Cases with Tumors Far from Major Vessels.

Cancers (Basel) 2021 Jun 25;13(13). Epub 2021 Jun 25.

Department of Hepato-Biliary Surgery and Transplantation, Hepatobiliary Centre, Paul Brousse Hospital, Villejuif 94800, France.

Less morbidity is considered among the advantages of laparoscopic liver resection (LLR) for HCC patients. However, our previous international, multi-institutional, propensity score-based study of emerging laparoscopic repeat liver resection (LRLR) failed to prove this advantage. We hypothesize that these results may be since the study included complex LRLR cases performed during the procedure's developing stage. To examine it, subgroup analysis based on propensity score were performed, defining the proximity of the tumors to major vessels as the indicator of complex cases. Among 1582 LRLR cases from 42 international high-volume liver surgery centers, 620 cases without the proximity to major vessels (more than 1 cm far from both first-second branches of Glissonian pedicles and major hepatic veins) were selected for this subgroup analysis. A propensity score matching (PSM) analysis was performed based on their patient characteristics, preoperative liver function, tumor characteristics and surgical procedures. One hundred and fifteen of each patient groups of LRLR and open repeat liver resection (ORLR) were earned, and the outcomes were compared. Backgrounds were well-balanced between LRLR and ORLR groups after matching. With comparable operation time and long-term outcome, less blood loss (283.3±823.0 vs. 603.5±664.9 mL, = 0.001) and less morbidity (8.7 vs. 18.3 %, = 0.034) were shown in LRLR group than ORLR. Even in its worldwide developing stage, LRLR for HCC patients could be beneficial in blood loss and morbidity for the patients with less complexity in surgery.
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http://dx.doi.org/10.3390/cancers13133187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8268302PMC
June 2021

Simultaneous evaluation of perfusion and morphology using GRASP MRI in hepatic fibrosis.

Eur Radiol 2021 Jun 12. Epub 2021 Jun 12.

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

Objectives: To determine if golden-angle radial sparse parallel (GRASP) dynamic contrast-enhanced (DCE)-MRI allows simultaneous evaluation of perfusion and morphology in liver fibrosis.

Methods: Participants who were scheduled for liver biopsy or resection were enrolled (NCT02480972). Images were reconstructed at 12-s temporal resolution for morphologic assessment and at 3.3-s temporal resolution for quantitative evaluation. The image quality of the morphologic images was assessed on a four-point scale, and the Liver Imaging Reporting and Data System score was recorded for hepatic observations. Comparisons were made between quantitative parameters of DCE-MRI for the different fibrosis stages, and for hepatocellular carcinoma (HCCs) with different LR features.

Results: DCE-MRI of 64 participants (male = 48) were analyzed. The overall image quality consistently stood at 3.5 ± 0.4 to 3.7 ± 0.4 throughout the exam. Portal blood flow significantly decreased in participants with F2-F3 (n = 18, 175 ± 110 mL/100 mL/min) and F4 (n = 12, 98 ± 47 mL/100 mL/min) compared with those in participants with F0-F1 (n = 34, 283 ± 178 mL/100 mL/min, p < 0.05 for all). In participants with F4, the arterial fraction and extracellular volume were significantly higher than those in participants with F0-F1 and F2-F3 (p < 0.05). Compared with HCCs showing non-LR-M features (n = 16), HCCs with LR-M (n = 5) had a significantly prolonged mean transit time and lower arterial blood flow (p < 0.05).

Conclusions: Liver MRI using GRASP obtains both sufficient spatial resolution for confident diagnosis and high temporal resolution for pharmacokinetic modeling. Significant differences were found between the MRI-derived portal blood flow at different hepatic fibrosis stages.

Key Points: A single MRI examination is able to provide both images with sufficient spatial resolution for anatomic evaluation and those with high temporal resolution for pharmacokinetic modeling. Portal blood flow was significantly lower in clinically significant hepatic fibrosis and mean transit time and extracellular volume increased in cirrhosis, compared with those in no or mild hepatic fibrosis. HCCs with different LR features showed different quantitative parameters of DCE-MRI: longer mean transit time and lower arterial flow were observed in HCCs with LR-M features.
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http://dx.doi.org/10.1007/s00330-021-08087-2DOI Listing
June 2021

Risk Factors Affecting Outcomes in Pediatric Liver Transplantation: A Real-World Single-Center Experience.

Ann Transplant 2021 May 28;26:e929145. Epub 2021 May 28.

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

BACKGROUND Despite liver transplantation (LT) being the standard treatment for pediatric end-stage liver disease, complications often persist and can adversely affect the post-transplant outcomes. This study aimed to identify the risk factors affecting the outcomes in pediatric LT patients. MATERIAL AND METHODS Data from pediatric patients who underwent primary LT from March 1988 to December 2018 were retrospectively analyzed. Chronic liver disease was defined as an explanted liver showing fibrosis regardless of grade, cirrhosis, or any other underlying disease that may cause progressive liver injury leading to fibrosis or cirrhosis. RESULTS A total of 255 pediatric patients underwent LT during the study period. Their 1-, 5-, and 10-year overall survival rates were 90.5%, 88.4%, and 87.8%, respectively. According to multivariate analysis, while liver disease without underlying chronic liver disease (P=0.024) and a pediatric end-stage liver disease (PELD) score ≥30 (P=0.036) were the only factors associated with worse survival, body weight <6 kg (P=0.050), whole-liver DDLT compared to LDLT (P=0.001), fulminant liver failure (P=0.008), and postoperative hepatic artery complications (P<0.001) were associated with worse graft survival. Liver disease without underlying chronic liver disease was the only factor independently associated with hepatic artery complications (P=0.003). CONCLUSIONS Greater caution is recommended in pediatric patients with liver disease unaccompanied by underlying chronic liver disease, high PELD score, or low body weight to improve survival after LT. Hepatic artery complication was the only surgical complication affecting the graft survival outcome, especially in patients having liver disease without underlying chronic liver disease.
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http://dx.doi.org/10.12659/AOT.929145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168285PMC
May 2021

Efficacy of Liver Resection for Single Large Hepatocellular Carcinoma in Child-Pugh A Cirrhosis: Analysis of a Nationwide Cancer Registry Database.

Front Oncol 2021 30;11:674603. Epub 2021 Apr 30.

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

Background: Therapeutic strategies and good prognostic factors are important for patients with single large hepatocellular carcinoma (HCC). This retrospective study aimed to identify the prognostic factors in patients with single large HCC with good performance status and Child-Pugh A cirrhosis using a large national cancer registry database and to recommend therapeutic strategies.

Methods: Among 12139 HCC patients registered at the Korean Primary Liver Cancer Registry between 2008 and 2015, single large (≥ 5 cm) HCC patients with Eastern Cooperative Oncology Group (ECOG) performance status 0 and Child-Pugh score A were selected.

Results: Overall, 466 patients were analyzed. The 1-,2-,3-, and 5-year survival rates after initial treatment were 84.9%, 71.0%, 60.1%, and 51.6%, respectively, and progression-free survival rates were 43.6%, 33.0%, 29.0%, and 26.8%, respectively. Platelet count < 100 × 10/L ( < 0.001), sodium level < 135 mmol/L ( = 0.002), maximum tumor diameter ≥ 10 cm ( = 0.001), and treatment other than resection (transarterial therapy vs. resection: < 0.001, others vs. resection: = 0.002) were significantly associated with poorer overall survival; sodium < 135 mmol/L ( = 0.015), maximum tumor diameter ≥ 10 cm ( < 0.001), and treatment other than resection (transarterial therapy vs. resection: < 0.001, others vs. resection: = 0.001) were independently associated with poorer progression-free survival.

Conclusion: Resection as an initial treatment should be considered when possible, even in patients with single large HCC with good performance status and mild cirrhosis. Caution should be exercised in patients with low platelet level (< 100 × 10/L), low serum sodium level (< 135 mmol/L), and maximum tumor diameter ≥ 10 cm.
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http://dx.doi.org/10.3389/fonc.2021.674603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8121000PMC
April 2021

Advances in the surgical outcomes of 300 cases of pure laparoscopic living donor right hemihepatectomy divided into three periods of 100 cases: a single-centre case series.

Ann Transl Med 2021 Apr;9(7):553

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

Background: Minimally invasive surgery has been widely used for hepatobiliary operations. This study aimed to determine the safety and feasibility of pure laparoscopic living donor right hepatectomy.

Methods: From November 2015 to April 2019, 300 cases of adult pure laparoscopic living donor right hepatectomy performed at Seoul National University Hospital were divided into three subgroups of periods 1-3 of 100 cases each: 1-100, 101-200, and 201-300, respectively. We retrospectively reviewed and analysed the safety and feasibility outcomes.

Results: The operative time (period 1: 318.9±62.2 min, period 2: 256.7±71.4 min, period 3: 227.7±57.4 min) and blood loss (period 1: 419.7±196.5 mL, period 2: 198.9±197.2 mL, period 3: 166.0±130.0 mL) gradually decreased (P<0.01). Similarly, the length of hospital stay decreased (period 1: 8.1±2.0 days, period 2: 7.3±3.1 days, period 3: 6.9±2.4 days, P<0.01). There was no requirement for intraoperative transfusions or care in the intensive care unit. The overall complication rate was 20/300 (6.7%), of which 8/300 (2.7%) were Clavien-Dindo grade III and above. Complications were not different among the three periods. In terms of anatomical variations, the incidences of multiple portal veins, multiple hepatic arteries, and multiple bile ducts were 32/300 (10.7%), 11/300 (3.7%), and 161/300 (53.7%), respectively. No differences were found among the three periods.

Conclusions: Owing to the technical improvements over time, pure laparoscopic living donor hepatectomy is currently feasible and safe even for donors with anatomical variations.
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http://dx.doi.org/10.21037/atm-20-6886DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8105826PMC
April 2021

Perioperative ABO Blood Group Isoagglutinin Titer and the Risk of Acute Kidney Injury after ABO-Incompatible Living Donor Liver Transplantation.

J Clin Med 2021 Apr 14;10(8). Epub 2021 Apr 14.

Department of Anesthesiology and Pain medicine, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-GU, Seoul 03080, Korea.

For ABO-incompatible liver transplantation (ABO-i LT), therapeutic plasma exchange (TPE) is performed preoperatively to reduce the isoagglutinin titer of anti-ABO blood type antibodies. We evaluated whether perioperative high isoagglutinin titer is associated with postoperative risk of acute kidney injury (AKI). In 130 cases of ABO-i LT, we collected immunoglobulin (Ig) G and Ig M isoagglutinin titers of baseline, pre-LT, and postoperative peak values. These values were compared between the patients with and without postoperative AKI. Multivariable logistic regression analysis was used to evaluate the association between perioperative isoagglutinin titers and postoperative AKI. Clinical and graft-related outcomes were compared between high and low baseline and postoperative peak isoagglutinin groups. The incidence of AKI was 42.3%. Preoperative baseline and postoperative peak isoagglutinin titers of both Ig M and Ig G were significantly higher in the patients with AKI than those without AKI. Multivariable logistic regression analysis showed that preoperative baseline and postoperative peak Ig M isoagglutinin titers were significantly associated with the risk of AKI (baseline: odds ratio 1.06, 95% confidence interval 1.02 to 1.09; postoperative peak: odds ratio 1.08, 95% confidence interval 1.04 to 1.13). Cubic spline function curves show a positive relationship between the baseline and postoperative peak isoagglutinin titers and the risk of AKI. Clinical outcomes other than AKI were not significantly different according to the baseline and postoperative peak isoagglutinin titers. Preoperative high initial and postoperative peak Ig M isoagglutinin titers were significantly associated with the development of AKI. As the causal relationship between high isoagglutinin titers and risk of AKI is unclear, the high baseline and postoperative isoagglutinin titers could be used simply as a warning sign for the risk of AKI after liver transplantation.
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http://dx.doi.org/10.3390/jcm10081679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8070732PMC
April 2021

Long-Term Outcomes of Abdominal Wall Reconstruction with Expanded Polytetrafluoroethylene Mesh in Pediatric Liver Transplantation.

J Clin Med 2021 Apr 2;10(7). Epub 2021 Apr 2.

Department of Surgery, Seoul National University Hospital, Seoul 08826, Korea.

Background: Large-for-size syndrome caused by organ size mismatch increases the risk of abdominal compartment syndrome. Massive transfusion and portal vein clamping during liver transplantation may cause abdominal compartment syndrome (ACS) related to mesenteric congestion. In general pediatric surgery-such as correcting gastroschisis-abdominal wall reconstruction for the reparation of defects using expanded polytetrafluoroethylene is an established method. The purpose of this study is to describe the ePTFE-Gore-Tex closure method in patients with or at a high risk of ACS among pediatric liver transplant patients and to investigate the long-term prognosis and outcomes.

Methods: From March 1988 to March 2018, 253 pediatric liver transplantation were performed in Seoul National University Hospital. We retrospectively reviewed the cases that underwent abdominal wall reconstruction with ePTFE during liver transplantation.

Results: A total of 15 cases underwent abdominal closure with ePTFE-GoreTex graft. We usually used a 2 mm × 10 cm × 15 cm sized Gore-Tex graft for extending the abdominal cavity. The median follow up was 59.5 (17-128.7) months and there were no cases of ACS after transplantation. There were no infectious complications related to ePTFE implantation. The patient and graft survival rate during the study period was 93.3% (14/15).

Conclusions: Abdominal wall reconstruction using ePTFE is feasible and could be an alternative option for patients with a high risk of ACS.
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http://dx.doi.org/10.3390/jcm10071462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8037026PMC
April 2021

Stage IV Classical Hodgkin Lymphoma-type Posttransplant Lymphoproliferative Disorder in a Pediatric Liver Transplant Patient: A Case Report and Review of the Literature.

J Pediatr Hematol Oncol 2021 Oct;43(7):e1015-e1019

Departments of Pediatrics.

Posttransplant lymphoproliferative disorder (PTLD) is a heterogeneous group of diseases with abnormal proliferation of lymphoid tissue and classical Hodgkin lymphoma (CHL) type PTLD is a very rare subtype. We describe a successfully diagnosed and treated CHL-PTLD stage IV pediatric patient, 8 years after liver transplantation. The patient was treated with standard CHL (Children's Cancer Group 5942 group 3) chemotherapy, rituximab and reduction of immunosuppressant. The patient remains in complete remission after 3 years with stable graft function. To our best knowledge, this is the first pediatric case report of a successfully treated stage IV CHL-PTLD after a liver transplant.
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http://dx.doi.org/10.1097/MPH.0000000000002121DOI Listing
October 2021

Efficacy and Safety of Everolimus With Reduced Tacrolimus in Liver Transplant Recipients: 24-month Results From the Pooled Analysis of 2 Randomized Controlled Trials.

Transplantation 2021 07;105(7):1564-1575

University of Toronto, Toronto, Canada.

Background And Methods: Data from 2 randomized liver transplant trials (N = 772; H2304 [deceased donor, n = 488], H2307 [living donor, n = 284]) were pooled to further evaluate the efficacy and safety of everolimus with reduced tacrolimus (EVR + rTAC) versus standard tacrolimus (sTAC) regimen at month 24.

Results: EVR + rTAC was comparable to sTAC for composite efficacy failure of treated biopsy-proven acute rejection, graft loss, or death (9.8% versus 10.8%; difference, -1.0%; 95% confidence interval, -5.4 to 3.4; P = 0.641) at month 24. EVR + rTAC was superior to sTAC for the mean change in estimated glomerular filtration rate (eGFR) from randomization to month 24 (-8.37 versus -13.40 mL/min/1.73 m2; P = 0.001). A subanalysis of renal function by chronic kidney disease (CKD) stage at randomization showed significantly lower decline in eGFR from randomization to month 24 for patients with CKD stage 1/2 (eGFR ≥ 60 mL/min/1.73 m2) in EVR + rTAC group versus sTAC (-12.82 versus -17.67 mL/min/1.73 m2, P = 0.009). In patients transplanted for hepatocellular carcinoma (HCC) beyond Milan criteria, HCC recurrence was numerically lower although not statistically significant with EVR + rTAC versus sTAC group (5.9% [1 of 17] versus 23.1% [6 of 26], P = 0.215), while comparable in patients within Milan criteria (2.9% [3 of 102] versus 2.1% [2 of 96], P = 1.000), irrespective of pretransplant alpha-fetoprotein levels.

Conclusions: EVR + rTAC versus sTAC showed comparable efficacy and safety with significantly better renal function, particularly in patients with normal/mildly decreased renal function (CKD stage 1/2) at randomization and a trend toward lower HCC recurrence in patients transplanted with HCC beyond Milan at month 24. Further long-term data would be required to confirm these results.
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http://dx.doi.org/10.1097/TP.0000000000003394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8221719PMC
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

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 06;27(6):830-839

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

Indocyanine green (ICG) near-infrared fluoroscopy has been recently implemented in pure laparoscopic donor hepatectomy (PLDH). This study aims 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 both midplane dissection and bile duct division. Retrospective analysis was done with images acquired from recordings of PLDH performed without ICG (pre-ICG group) from November 2015 to May 2016 and with ICG (post-ICG group) from June 2016 to May 2017. 30 donors from the pre-ICG group were compared with 46 donors from the post-ICG group. The operation time was shorter (P = 0.002) and postoperative 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 versus nonclamped regions in the natural, black-and-white, and fluorescent modes were 39.7 ± 36.2, 89.6 ± 46.9, and 19.1 ± 36.8 (mean ± SD, 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. Meanwhile, 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 minutes. All grafts received from the 46 donors were successfully transplanted. In conclusion, ICG fluoroscopy helps to reduce operation time and lower postoperative AST/ALT levels. ICG injection visualized with black-and-white imaging is most effective for demarcating the liver midplane during PLDH. A single intravenous injection of 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
June 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

Should Lymph Nodes Be Retrieved in Patients with Intrahepatic Cholangiocarcinoma? A Collaborative Korea-Japan Study.

Cancers (Basel) 2021 Jan 25;13(3). Epub 2021 Jan 25.

Department of Surgery, Sungkyunkwan University School of Medicine, Seoul 16419, Korea.

Background: This study was performed to investigate the oncologic role of lymph node (LN) management and to propose a surgical strategy for treating intrahepatic cholangiocarcinoma (IHCC).

Methods: The medical records of patients with resected IHCC were retrospectively reviewed from multiple institutions in Korea and Japan. Short-term and long-term oncologic outcomes were analyzed according to lymph node metastasis (LNM). A nomogram to predict LNM in treating IHCC was established to propose a surgical strategy for managing IHCC.

Results: A total of 1138 patients were enrolled. Of these, 413 patients underwent LN management and 725 did not. A total of 293 patients were found to have LNM. The No. 12 lymph node (36%) was the most frequent metastatic node, and the No. 8 lymph node (21%) was the second most common. LNM showed adverse long-term oncologic impact in patients with resected IHCC (14 months, 95% CI (11.4-16.6) vs. 74 months, 95% CI (57.2-90.8), < 0.001), and the number of LNM (0, 1-3, 4≤) was also significantly related to negative oncologic impacts in patients with resected IHCC (74 months, 95% CI (57.2-90.8) vs. 19 months, 95% CI (14.4-23.6) vs. 11 months, 95% CI (8.1-13.8)), < 0.001). Surgical retrieval of more than four (≥4) LNs could improve the survival outcome in resected IHCC with LNM (13 months, 95% CI (10.4-15.6)) vs. 30 months, 95% CI (13.1-46.9), = 0.045). Based on preoperatively detectable parameters, a nomogram was established to predict LNM according to the tumor location. The AUC was 0.748 (95% CI: 0.706-0.788), and the Hosmer and Lemeshow goodness of fit test showed = 0.4904.

Conclusion: Case-specific surgical retrieval of more than four LNs is required in patients highly suspected to have LNM, based on a preoperative detectable parameter-based nomogram. Further prospective research is needed to validate the present surgical strategy in resected IHCC.
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http://dx.doi.org/10.3390/cancers13030445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7865580PMC
January 2021

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

Eur Radiol 2021 Aug 18;31(8):5802-5811. 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
August 2021

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

Am J Transplant 2021 09 8;21(9):2978-2991. Epub 2021 Feb 8.

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
September 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 03 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
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