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Pure Laparoscopic Left Lateral Sectionectomy for Living Donor with Anatomic Variation
( Jae Hyun Kwon ),( Ki-hun Kim ),( Shin Hwang ),( Chul-soo Ahn ),( Deok- Bog Moon ),( Tae-yong Ha ),( Gi-won Song ),( Dong-hwan Jung ),( Gil- Chun Park ),( Hwui-dong Cho ),( Yongkyu Chung ),( Sumin Ha 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1
Aims: In adult-to-child living donor liver transplantation (LDLT), a pure laparoscopic donor left lateral sectionectomy could be considered as a standard practice with emerging evidences supporting its feasibility and safety. The pure laparoscopic left lateral sectionectomy for living donor with anatomic variations in hepatic artery and bile duct is presented. Methods: After intraoperative frozen biopsy of the liver and cholecystectomy, mobilization of left side of liver was done through division of falciform ligament, followed by left coronary ligament and triangular ligament division. Thereafter during the division of gastrohepatic ligament, aberrant left hepatic artery originating from left gastric artery was identified and taped with vessel loop. Hilar dissection with identification of middle hepatic artery and left portal vein was performed. Parenchymal division was performed using a combination of CUSA and energy device on the right side of falciform ligament and umbilical fissure. Three times of vascular clamping were used during parenchymal transection. As division of the hepatic parenchyme was completed, left bile duct transection was performed after confirming aberrant right posterior hepatic duct drainage into left hepatic duct through intraoperative cholangiography with fluoroscopy. Procurement of left lateral section graft was performed followed by retrieval through suprapubic transverse incision. Results: Donor recovery was not eventful and discharged 8 days after the operation. Follow-up CT and hepatobiliary scan after the operation showed no abnormal findings. Conclusions: Pure laparoscopic living donor left lateral sectionectomy with complicated anatomic variations could be safely performed and feasible option for living liver donors even with these kinds of aberrant anatomy.
Clinical Outcomes of Re-Transplantation: A Single-Center Experience
( Jae Hyun Kwon ),( Gi Won Song ),( Shin Hwang ),( Ki Hun Kim ),( Chul Soo Ahn ),( Deok Bog Moon ),( Tae Yong Ha ),( Dong Hwan Jung ),( Wan Joon Kim ),( Sung Gyu Lee ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1
Aims: Re-transplantation is the only therapeutic option for irreversible graft failure. The aim of this study is to analyze a single center’s experience of the outcome of liver re-transplantation and reviewed the technical feasibility and possibility of living donor re-transplantation as another option of re-transplantation. Methods: All patients who underwent LT twice or more at Asan Medical Center between February 1994 and December 2014 were included. Total 4428 liver transplantation (living donor liver transplantation (LDLT) 3743 cases, deceased donor liver transplantation (DDLT) 685 cases) were performed at our institute. To compare clinical outcomes including graft and patient survival rate, we defined the patients who underwent LT once during same period as control group. Results: Among 4428 cases of total LT cases during the study period, adult LT were 4196 cases and pediatric LT were 232 cases. 146 cases (3.3%) were performed as re-LT. Adult re-LT were 126 cases (86.3%) and pediatric re-LT were 20 cases (13.7%). The mean age of 146 recipients of re-LT was 41.5±17.2 (1.2~68) years old. 98 patients (67.1%) were male and 48 (32.9%) were female. The overall 1-, 3-, 5- and 10-year survival rates following primary LT were 91.6%, 83.9%, 82.2%, 78.2% respectively. And the overall 1-, 3-, 5- and 10-year survival rates following re-LT were 68.3%, 61.2%, 58.5%, 58.5%. In multivariate analysis, MELD>20 (P=0.000), ventilator support (P=0.023), Age>16 (P=0.000), bacteremia (P=0.032) and pneumonia (P=0.021) reached statistical significance which affecting the survival rate of re-LT patients. Conclusions: Overall survival of re-transplantation patients has improved in recent years. If we could overcome the technical issues and medical problems in these patients, living donor re-transplantation would be another option for shortening the waiting period of cadaveric donor and consequently preventing deterioration of medical problem in recipients.
( Jae Hyun Kwon ),( Gi-won Song ),( Shin Hwang ),( Ki-hun Kim ),( Chul-soo Ahn ),( Deok-bog Moon ),( Tae-yong Ha ),( Dong-hwan Jung ),( Gil-chun Park ),( Sung-gyu Lee ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1
Aims: HCV universally recurs after liver transplantation. Although the introduction of direct-acting antiviral agents (DAAs) has revolutionized the treatment of HCV infection, no optimal treatment for HCV recurrence after liver transplantation has been developed. Methods: This study retrospectively evaluated the efficacy of DAAs as a pre-emptive treatment for recurrent HCV infection after living donor liver transplantation (LDLT). From January 2010 to December 2016, 105 patients received LDLT followed by either pegylated interferon (PegIFN) or a DAA-based regimen to treat recurrent HCV. All antiviral treatments were pre-emptive. Results: After LDLT, 70 patients received PegIFN and 35 received a DAA. Genotype 1b was the most common HCV type (61.9%), followed by 2a (27.6%). Twenty-two recipients in the DAA group were treated with ledipasvir/sofosbuvir, nine received daclatasvir plus asunaprevir, three received sofosbuvir, and one received sofosbuvir plus daclatasvir. All 35 patients (100%) in the DAA group achieved a sustained virologic response (SVR), a percentage significantly higher than that (71.4%) in the PegIFN group (P<0.001). Recipients in the DAA group also showed a significantly stronger early virologic response (EVR) and an end-of-treatment virologic response (ETVR). In the PegIFN group, the 1, 3, and 5 year graft survival rates after LDLT were 85.7%, 73.9%, and 70.7%, respectively, whereas those in the DAA group were significantly higher, at 100%, 100%, and 100%, respectively (P=0.008). Conclusions: DAA-based regimens are an effective treatment for HCV recurrence after LDLT, resulting in an improved SVR and better graft survival than PegIFN-based treatments.
Conjoined unification venoplasty for triple portal vein branches of right liver graft
Jae Hyun Kwon,Shin Hwang,Gi-Won Song,Deok-Bog Moon,Gil-Chun Park,Seok-Hwan Kim,Sung-Gyu Lee 한국간담췌외과학회 2016 Annals of hepato-biliary-pancreatic surgery Vol.20 No.2
Anomalous portal vein (PV) branching of the donor liver is uncommon and usually makes two, or rarely, more separate PV branches at the right liver graft. Autologous PV Y-graft interposition has long been regarded as the standard procedure, but is currently replaced with the newly developed technique of conjoined unification venoplasty (CUV) due to its superior results. Herein, we presented a case of CUV application to three PV openings of a right liver graft. The recipient was a 32-year-old male patient with hepatitis B virus-associated liver cirrhosis. The living liver donor was his 33-year-old sister who had a type III PV anomaly, but the right posterior PV branch was bifurcated early into separate branches of the segments VI and VII, thus three right liver PV branches were cut separately. We used the CUV technique consisting of placement of a small vein unification patch between three PV orifices, followed by overlying coverage with a crotch-opened autologous portal Y-graft. The portal Y-graft was excised and its crotches were incised to make a wide common orifice. Three bidirectional running sutures were required to attach the crotch-opened autologous portal Y-graft. After portal reperfusion, the conjoined PV portion bulged like a tennis ball, providing a wide range of alignment tolerance. The patient recovered uneventfully from the liver transplantation operation. The CUV technique enabled uneventful reconstruction of triple donor PV orifices. Thus, CUV can be a useful and effective technical option for reconstruction of right liver grafts with various anomalous PVs.
Conjoined unification venoplasty for triple portal vein branches of right liver graft
Jae Hyun Kwon,Shin Hwang,Gi-Won Song,Deok-Bog Moon,Gil-Chun Park,Seok-Hwan Kim,Sung-Gyu Lee 한국간담췌외과학회 2016 한국간담췌외과학회지 Vol.20 No.2
Anomalous portal vein (PV) branching of the donor liver is uncommon and usually makes two, or rarely, more separate PV branches at the right liver graft. Autologous PV Y-graft interposition has long been regarded as the standard procedure, but is currently replaced with the newly developed technique of conjoined unification venoplasty (CUV) due to its superior results. Herein, we presented a case of CUV application to three PV openings of a right liver graft. The recipient was a 32-year-old male patient with hepatitis B virus-associated liver cirrhosis. The living liver donor was his 33-year-old sister who had a type III PV anomaly, but the right posterior PV branch was bifurcated early into separate branches of the segments VI and VII, thus three right liver PV branches were cut separately. We used the CUV technique consisting of placement of a small vein unification patch between three PV orifices, followed by overlying coverage with a crotch-opened autologous portal Y-graft. The portal Y-graft was excised and its crotches were incised to make a wide common orifice. Three bidirectional running sutures were required to attach the crotch-opened autologous portal Y-graft. After portal reperfusion, the conjoined PV portion bulged like a tennis ball, providing a wide range of alignment tolerance. The patient recovered uneventfully from the liver transplantation operation. The CUV technique enabled uneventful reconstruction of triple donor PV orifices. Thus, CUV can be a useful and effective technical option for reconstruction of right liver grafts with various anomalous PVs.
Seung-Jae Lee,Shin Hwang,Tae-Yong Ha,Ki-Hun Kim,Chul-Soo Ahn,Deok-Bog Moon,Gi-Won Song,Dong-Hwan Jung,Gil-Chun Park,Sung-Gyu Lee 한국간담췌외과학회 2013 한국간담췌외과학회지 Vol.17 No.3
Backgrounds/Aims: Mid bile duct cancers often involve the proximal intrapancreatic bile duct, and resection of the extrahepatic bile duct (EHBD) can result in a tumor-positive distal resection margin (RM). We attempted a customized surgical procedure to obtain a tumor-free distal RM during EHBD resection, so that R0 resection can be achieved without performing pancreaticoduodenectomy through extended EHBD resection. Methods: We previously reported the surgical procedures of extended EHBD resection, in which the intrapancreatic duct excavation resembles a ≥2 cm-long funnel. This unique procedure was performed in 11 cases of mid bile duct cancer occurring in elderly patients between the ages of 70 and 83 years. Results: The tumor involved the intrapancreatic duct in all cases. Deep pancreatic excavation per se required about 30-60 minutes. Cancer-free hepatic duct RM was obtained in 10 patients. Prolonged leakage of pancreatic juice occurred in 2 patients, but all were controlled with supportive care. Adjuvant therapies were primarily applied to RM-positive or lymph node-positive patients. Their 1-year and 3-year survival rates were 90.9% and 60.6%, respectively. Conclusions: We suggest that extended EHBD resection can be performed as a beneficial option to achieve R0 resection in cases in which pancreaticoduodenectomy should be avoided due to various causes including old age and expectation of a poor outcome.
( Shin Hwang ),( Su-min Ha ),( Chul-soo Ahn ),( Ki-hun Kim ),( Deok-bog Moon ),( Tae-yong Ha ),( Gi-won Song ),( Dong-hwan Jung ),( Gil-chun Park ),( Hwi-dong Cho ),( Jae-hyun Kwon ),( Sang-hyun Kang 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1
Aims: This study aimed to assess patterns of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) and to establish long-term surveillance protocols for late HCC recurrence. Methods: The 232 LT recipients experiencing subsequent HCC recurrence were categorized as Group 1, early recurrence (within 1 year of LT; n=117); Group 2, late recurrence (occurring in years 2-5; n=93); and Group 3, very late recurrence (after year 5; n=22). Results: Recurrence was detected by only elevated tumor marker levels in 11.1%, 30.1%, and 45.5% of patients in Groups 1, 2, and 3, respectively (P<0.001). The proportion of intrahepatic and extrahepatic metastases was similar in all three groups. Common sites of extrahepatic metastasis were the lung and bone; these were also similar across the three groups. Overall post-recurrence patient survival rates were 60.2% at 1 year, 28.2% at 3 years, 20.5% at 5 years, and 7.0% at 10 years. Median post-recurrence survival periods were 10.2, 23.8, and 37.0 months in Groups 1, 2, and 3, respectively. Conclusions: While the pattern of HCC recurrence was similar regardless of time of recurrence, post-recurrence survival was significantly longer in patients with later recurrence. Long-term surveillance for HCC recurrence beyond 5 years post-LT is recommended.