Nevin Manimala

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S189. doi: 10.14701/ahbps.LV-PP-3-2.

ABSTRACT

INTRODUCTION: Caudate lobes are anatomically located between the hepatic hilum and inferior vena cava. Isolated caudate lobectomy is still a challenging procedure for hepatobiliary pancreas surgeons because it is quite complicated depending on the relationship between the surrounding major vascular structures and the biliary tract. In this study, we introduce a various surgical strategy for hepatocellular carcinoma located in the caudate lobe, and report the results.

METHODS: From January 2005 to December 2015, 35 patients who underwent caudate lobectomy due to hepatocellular carcinoma in Seoul National University Hospital were enrolled. We described several surgical strategies with hanging maneuver and compared the clinical outcomes between the radical resection group and the local resection group.

RESULTS: A total of 35 patients underwent hepatectomy including the caudate lobe. The median follow-up period was 86.7 months (3.8-183.6 months). There was 2 (5.7%) extended right hemihepatectomy, 2 (5.7%) extended left hemihepatectomy, 2 (5.7%) right posterior sectionectomy including caudate lobe, 12 (34.3%) cases of isolate caudate lobectomy, and 15 (42.9%) cases of local tumorectomy (non-anatomical). There was no statistically significant differences were observed in operative time, hospital stay, and complication rate (mean, 247.1 ± 104.7 minutes vs. 247.1 ± 104.7 minutes, p = 0.729; mean, 10.2 ± 6.68 days vs. 10.2 ± 6.14 days, p = 1.000). The rates of recurrence were significantly lower in the radical resection groups than in the local resection group (13/15, 86.7% vs. 10/20, 50.0%; p = 0.034).

CONCLUSIONS: Various surgical strategies are necessary to resect caudate tumors depending on the location and degree of invasion. These several methods would be helpful to reduce recurrence without complications.

PMID:34227549 | DOI:10.14701/ahbps.LV-PP-3-2

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S186. doi: 10.14701/ahbps.LV-PP-2-5.

ABSTRACT

INTRODUCTION: Adult-to-adult living donor liver transplantation (LDLT) has been a dominant type of liver transplantation, especially in Asian countries where deceased donors are extremely scarce. Several centers have been attempted to use left liver graft because it could reduce the postoperative risk to the donor. This study retrospectively compared clinical outcomes between right and left liver grafts in adult-to-adult LDLT.

METHODS: All consecutive 116 patients who underwent adult-to-adult LDLT between 2010 and 2020 were enrolled in this study. The study cohort comprised of 94 patients in the right liver (RL) group and 22 in the left liver (LL) group. When both hemiliver grafts meet the selection criteria, LL graft was preferred. Prospectively collected clinicopathologic characteristics, perioperative outcomes, and survival were evaluated.

RESULTS: In terms of donor variables, median actual graft-to-recipient weight ratio was higher in the RL group than in the LL group (1.01 [0.66-1.66] vs. 0.85 [0.63-1.50], p = 0.030). Total bilirubin level and prothrombin time on postoperative day 5 were worse in the RL group, but it did not reach statistical significance. In terms of recipient variables, hepatic venous pressure gradient after reperfusion was comparable between the groups. The 90-day complication (above Clavien-Dindo grade IIIA) and 1-year graft survival rates were not different between the RL and LL groups (35.9% vs. 56.2%, p = 0.123; 91.3% vs. 93.8%, p = 0.744; respectively).

CONCLUSIONS: This study demonstrated comparable donor and recipient outcomes between the RL and LL groups. In an effort to minimize potential donor risk, LL graft is worth considering when both grafts meet the selection criteria.

PMID:34227546 | DOI:10.14701/ahbps.LV-PP-2-5

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S182. doi: 10.14701/ahbps.LV-PP-2-1.

ABSTRACT

INTRODUCTION: For the APRI and FIB-4 index, which are one of the non-invasive methods of examining the degree of liver fibrosis, our paper aims to examine the implications for predicting the prognosis in hepatocellular carcinoma patients undergoing hepatectomy.

METHODS: Between 2006 and 2013, total 973 patients were underwent hepatic resection due to hepatocellular carcinoma and 871 patients were enrolled in our study after adjusting exclusion criteria. Statistics were performed by calculating the optimal cut off values for the recurrence free survival and overall survival of each group which are categorized by etiology and multivariate analysis were performed for evaluating the performance of index.

RESULTS: Among the causes of HCC patients, HBV (n = 629, 72%) was the most common, and men were dominant in all groups. In each group divided by etiology, the area under the receiver operating characteristics of APRI and FIB-4 for recurrence free survival and overall survival were relatively higher in HCV patients than in other groups. After setting the cut-off value through the Youden index, univariate analysis and multivariate analysis for RFS and OS of all groups were performed, and the results of APRI values for RFS in each group were statistically significant (HBV : OR = 1.849, p = 0.001; HCV : OR = 6,548, p = 0.010; Alcohol : OR = 3.393, p = 0.004).

CONCLUSIONS: The significance of this study is that these simple laboratory findings are meaningful in revealing the prognosis of HCC patients, which can be predicted accurately only after the pathologic staging after surgery.

PMID:34227542 | DOI:10.14701/ahbps.LV-PP-2-1

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S181. doi: 10.14701/ahbps.LV-PP-1-6.

ABSTRACT

INTRODUCTION: Depending on the recipient’s condition and lack of donors, even liver grafts with poor conditions may need to be transplanted. This study was conducted to analyze the outcomes after receiving a liver graft that abandoned transplantation due to poor graft conditions at the preceding centers.

METHODS: From January 2010 to September 2020, deceased-donor liver transplantation (DDLT) was performed in 161 patients in our center. Among them, 127 patients (allocated group) were preferentially allocated to our center by KONOS and the remaining 34 patients (abandoned group) received liver grafts that were abandoned by other transplant centers due to poor organ conditions. Various perioperative factors and postoperative outcomes were compared.

RESULTS: There was no difference in recipient factors before transplantation, and the donor had a longer stay in the ICU in the abandoned group. The operation time was less in the abandoned group, but there was no statistical difference (p = 0.06), and there was no difference in ischemic time or transfusion between the two groups. Postoperative ICU hospital stay was longer in the abandoned group (p = 0.04), but postoperative in-hospital mortality was not different between the two groups. There was no difference between the two groups in long term survival after transplantation.

CONCLUSIONS: Even if the graft that was abandoned due to poor condition, good results can be obtained if the transplant is carried out according to the recipient state. And as a result, it is expected that the discarded graft can be reduced.

PMID:34227541 | DOI:10.14701/ahbps.LV-PP-1-6

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S177. doi: 10.14701/ahbps.LV-PP-1-2.

ABSTRACT

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

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

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

CONCLUSIONS: This study suggests that positive graft weight change during HTK solution perfusion indicates poor prognosis in LDLT.

PMID:34227537 | DOI:10.14701/ahbps.LV-PP-1-2

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S175. doi: 10.14701/ahbps.BP-PP-4-7.

ABSTRACT

INTRODUCTION: It is known that gallbladder cancer (GBC) in the neck or cystic duct (NC-GBC) has a better prognosis than GBC in the fundus or body (FB-GBC), but systematic studies on this are insufficient. We performed this study to investigate the impact of longitudinal tumor location on postoperative outcomes in patients undergoing resection for GBC.

METHODS: A retrospective study was conducted for patients who underwent a radical resection for GBC from February 2008 to November 2017 at the Dankook University Hospital. A total of 98 patients underwent surgery for GBC, of which 77 patients who underwent curative intent surgery were included in the study. They were classified into FB-GBC and NC-GBC groups according to longitudinal tumor location, and the postoperative outcomes were compared and analyzed.

RESULTS: There were no significant differences in the clinicopathological characteristics, TNM stage, postoperative complications, and in-hospital mortality between two groups. However, NC-GBC significantly showed more sclerotic gross type, poorer differentiation, and more lymphatic and perineural microinvasion. The radical resection rate was statistically higher in FB-GBC group (93.1% vs. 73.7%; p = 0.036) and adjuvant 5-FU based CCRT was more carried out in NC-GBC group (19.0% vs. 57.9%; p < 0.001). The recurrence rates after surgery was statistically higher in NC-GBC group (25.9% vs. 52.6%, p = 0.047), but there were no differences in disease-free survival (DFS) and overall survival (OS).

CONCLUSIONS: Although NC-GBC showed more aggressive microscopic pathological findings and higher recurrence rate than FB-GBC, there were no differences in DFS and OS according to longitudinal tumor location of GBC.

PMID:34227535 | DOI:10.14701/ahbps.BP-PP-4-7

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S169. doi: 10.14701/ahbps.BP-PP-4-1.

ABSTRACT

INTRODUCTION: Extended cholecystectomy (EC) has been considered as the standard surgery of T2 gallbladder (GB) cancer. However, little is known an appropriate surgical strategy for intracholecystic papillary neoplasm (ICPN) of the GB, especially for the invasive ICPN. This study conducted to investigate clinicopathologic characteristics of T2 ICPN and compare the survival outcomes according to the surgical extent.

METHODS: This was a retrospective cohort study. Between 2003 and 2018, patients who underwent curative-intent simple cholecystectomy (SC) or EC were included. EC was defined as liver wedge resection with at least 2-cm margin from the GB and lymphadenectomy around hepatoduodenal ligament. Preoperative patients’ demographics and pathologic data were investigated.

RESULTS: Of total 96 patients with T2 ICPN, 29 (30.2%) and 67 (69.8%) patients underwent SC and EC, respectively. Age at surgery was older in SC than EC group (73.0 vs. 65.4 years, p = 0.002). Overall, EC group showed better survival outcome than SC group (5-year overall survival [5YSR], 83.3% vs. 49.8%, p = 0.001). However, statistical significance was not shown in patients with age ≥ 75 years (5YSR, EC 67.7% vs. SC 35.6%, p = 0.606). In a multivariate analysis, older age (≥ 75 years, HR 3.03; p = 0.009), higher preoperative CA 19-9 level (≥ 37 IU/mL; p = 0.001), histologic differentiation (moderate, HR 2.47; p = 0037), and surgical extent (SC, HR 2.58; p = 0.022) were independent risk factors for worse survival outcome in T2 ICPN. Systemic recurrence was more frequently in SC group (31.0% vs. 7.5%; p = 0.003).

CONCLUSIONS: Similar to the T2 GB cancer, EC should be the standard surgical extent of T2 ICPN.

PMID:34227529 | DOI:10.14701/ahbps.BP-PP-4-1

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S165. doi: 10.14701/ahbps.BP-PP-3-4.

ABSTRACT

INTRODUCTION: Incidental discovery of gallbladder cancer (GBC) on postoperative histopathology or intra-operative suspicion is becoming increasingly frequent, since laparoscopic cholecystectomy became the standard of care for gall stone disease. Incidental GBC (IGBC) portends a better survival than primarily detected GBC. Various factors affect the outcome of re-resection with timing of re-intervention an important determinant of survival.

METHODS: All patients of IGBC who underwent curative resection from January 2009 to December 2018 were considered for analysis. Details of demographic profile, index surgery, primary histopathology, operative findings on re-resection, final histopathology and follow-up data were retrieved from the prospectively maintained database. Patients were evaluated in three groups based on the interval between index cholecystectomy and re-intervention (early [< 4weeks], intermediate [4-12 weeks], and late [> 12 weeks]) using appropriate statistical tests.

RESULTS: Forty eight patients underwent re-resection with curative intent. Median age of presentation was 55 years. Mean and median follow-up was 51.6 and 40.6 months respectively (range, 1.2-130.6 months). The overall survival and disease free survival among the three groups was the best in ‘early’ group (104 & 102 months) as compared to the ‘Intermediate’ (84 & 83 months) and ‘late’ groups (75 & 73 months), though the difference was not statistically significant (p = 0.588 and p = 0.581). On Multivariate analysis, poor differentiation was the only independent factor affecting survival. Other attributes which were associated with poor outcome, but could not reach statistical significance were node metastasis, delay in re-resection, residual tumor, need for CBD excision and lymphovascular invasion.

CONCLUSIONS: Grade of tumor is the most important determinant of survival in IGBC. Early surgery, preferably within 4 weeks possibly entails better survival.

PMID:34227525 | DOI:10.14701/ahbps.BP-PP-3-4

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S162. doi: 10.14701/ahbps.BP-PP-3-1.

ABSTRACT

INTRODUCTION: Optimal timing of percutaneous transhepatic gallbladder drainage (PTGBD) and subsequent laparoscopic cholecystectomy (LC) according to the severity of acute cholecystitis (AC) is not established.

METHODS: Total 739 patients with AC without common bile duct stone who underwent PTGBD and subsequent LC from January 2010 to December 2019 were retrospectively reviewed. We defined difficult surgery (DS; open conversion, subtotal cholecystectomy, adjacent organ injury, transfusion, operative time ≥ 90 minutes, or estimated blood loss ≥ 100 milliliters) and poor postoperative outcomes (PPO; postoperative hospital stays ≥ 7 days, or postoperative complication ≥ grade II). The receiver operating characteristic analyses were performed for evaluating appropriate duration from onset of symptom to PTGBD (duration A) and from PTGBD to LC (duration B).

RESULTS: Of the 739 patients, 458 were for grade I AC, and 281 were for grade II/III AC. In grade I AC, the cut-off value for the relationship between duration A and PIO was 4.5 days. The cut-off value for the relationship between duration B and PPO was 7.5 days. In multivariate analysis, duration A ≥ 5 days and duration B ≥ 8 days were statistically significant predictors for DS and PPO, respectively. In grade II/III AC, the cut-off value for the relationship between duration A and PPO was 2.5 days. In multivariate analysis, duration A ≤ 2 days was statistically significant predictor for PPO.

CONCLUSIONS: Optimal timing of PTGBD and LC is for duration from onset of symptom to PTGBD ≤ 4 days with duration from PTGBD to LC ≤ 7 days in grade I AC, and for duration from onset of symptom to PTGBD > 2 days.

PMID:34227522 | DOI:10.14701/ahbps.BP-PP-3-1

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S158. doi: 10.14701/ahbps.BP-PP-2-4.

ABSTRACT

INTRODUCTION: Total pancreatectomy (TP) is mostly performed for diseases involving the entire pancreas including various pathology. However, there is still a reluctance to perform TP due to high postoperative morbidity or mortality, and life-long endocrine and exocrine pancreatic insufficiency. This retrospective study aimed to evaluate postoperative outcomes in a high-volume center and identify the risk factors affecting major morbidity and mortality after TP.

METHODS: From 1995 to 2015, a total of 142 patients who underwent elective TP at Samsung Medical Center were included in this study. One-stage TP was defined as elective primary TP, and in whom an intraoperative decision to extend the planned resection to TP, whereas 2-stage TP was elective completion TP due to recurred tumor. Patients who underwent TP in an emergency setting were excluded. Postoperative mobidity or pancreatectomy-specific complication was defined according to Clavien-Dindo classification (CDC) or ISGPF classification.

RESULTS: There were no statistically significant differences between 1-stage TP (n = 128) and 2-stage TP (n = 14) in clinical, operative, pathologic variables. Overall major morbidity more than CDC ≥ 3 or ISGPF grade B/C were occurred in 25 patients (17.6%). The readmission rate within 90-day including DM control was 20.4%. There was no in-hospital mortality among all enrolled patients. Multiple underlying diseases (OR, 3.350; 95% CI, 1.244-9.019; p = 0.017) and longer operative time (OR, 1.005; 95% CI, 1.000-1.010; p = 0.041) were identified an independent risk factors for major morbidity after multivariable analysis.

CONCLUSIONS: TP are safe and feasible procedures with satisfactory early surgical outcomes when performed at high-volume center.

PMID:34227518 | DOI:10.14701/ahbps.BP-PP-2-4