Anatomic variations of the portal vein (PV) and bile duct (BD) are more common on the right lobe as compared with left lobe grafts in living donor liver transplantation (LDLT). We recently experienced a case of LDLT for hepatocellular carcinoma combined with liver cirrhosis secondary to hepatitis B virus and hepatitis C virus infection. The only available donor had right lobe graft with type IV PV associated with type IV BD. The patient underwent relaparotomy for PV stenting due to PV stenosis. Percutaneous transhepatic biliary drainage was done for a stricture at the site of biliary reconstruction. Thereafter, the patient was discharged in good health. Our experience suggests that, the use of right lobe graft with type IV PV accompanied by type IV BD should be the last choice for LDLT, because of its technical difficulty and risks of associated complications.
Bile Ducts ; Biliary Tract* ; Carcinoma, Hepatocellular ; Constriction, Pathologic ; Drainage ; Hepacivirus ; Hepatitis B virus ; Humans ; Liver Cirrhosis ; Liver Transplantation* ; Living Donors* ; Portal Vein* ; Postoperative Complications ; Stents ; Tissue Donors ; Transplants*

BACKGROUNDS/AIMS: The prognosis of hepatic resection for hepatocellular carcinoma (HCC) in patients with cirrhosis is worse than in those without cirrhosis. In Korea, the hepatitis B virus prevalence rate is higher than in other countries. Therefore, we investigated patients' clinicopathologic and metabolic factors that affect the postoperative outcomes of hepatic resection for HCC in our hospital in Korea. METHODS: From August 2000 to December 2012, 171 HCC patients underwent hepatic resections at our institution. Two operative mortality cases and two short-term follow up cases were excluded. Data was collected from a retrospective chart review. There were 133 males (79.6%) and 34 females (20.3%), with a mean age of 58.2+/-10.2 years (range, 22-81 years), and the relationship between clinicopathologic and metabolic factors and the prognosis of patients with HCC undergoing hepatic resection were evaluated by univariate and multivariate analysis. RESULTS: Hypertension, major surgery, perioperative transfusion, resection with radiofrequency ablation (RFA) or cryoablation, and resection margin were risk factors for overall survival, and hypertension, albumin, resection with RFA or cryoablation, perioperative transfusion, and tumor size were risk factors for disease-free survival. CONCLUSIONS: We found that hypertension, perioperative transfusion, and resection with RFA or cryoablation were risk factors for both disease-free and overall survival after hepatic resection in HCC patients. Further study is required to clarify the influence of metabolic and other clinicopathologic factors on the prognosis of HCC.
Carcinoma, Hepatocellular* ; Catheter Ablation ; Cryosurgery ; Disease-Free Survival ; Female ; Fibrosis ; Follow-Up Studies ; Hepatitis B virus ; Humans ; Hypertension ; Korea ; Male ; Mortality ; Multivariate Analysis ; Prevalence ; Prognosis* ; Retrospective Studies ; Risk Factors

Although perioperative pulmonary thromboembolisms (PTEs) are not rare, most anesthetists are unfamilar with the condition. We experience a case, which showed a sudden capnographic score drop, increased pumonary arterial pressure, and a D-shaped right ventricle by echocardiography in a femur surgery patient under general anesthesia. The case described provides an example of PTE and should remind anesthetists of the clinical course and treatment of this condition.
Anesthesia, General* ; Arterial Pressure ; Echocardiography ; Femur* ; Heart Ventricles ; Humans ; Orthopedics ; Pulmonary Embolism* ; Thromboembolism

BACKGROUND: Most local anesthetics decrease neuromuscular transmission and potentiate the neuromuscular blocks of muscle relaxants. The purpose of this study was to examine the influence of lidocaine on it effects rocuronium onset and intubation conditions in rapid-sequence intubation and to compare with those of succinylcholine. METHODS: Seventy five ASA physical status 1 and 2 patients were randomly allocated to three groups. Group S received succinylcholine (1.0 mg/kg), Group R received rocuronium (0.6 mg/kg) and additional lidocaine (1.5 mg/kg) was given intravenously prior to the administration of rocuronium 0.6 mg/kg in Group RL. Anesthesia was induced with midazolam 0.03 mg/kg, fentanyl 2microgram/kg, and thiopental 5 mg/kg. Intubation was performed 60 seconds after the administration of muscle relaxants and intubation conditions were evaluated. Neuromuscular blockades were assessed by single twitch responses of the adductor pollicis after ulnar nerve stimulation by accelerography (0.1 Hz, 0.2 ms supramaximal stimuli). RESULTS: The onset time of Group S (47.8+/-11.3) was shorter than those of Group R (87.8+/-30.2) and Group RL (75.4+/-21.5), but no differences was observed between the onset times of Group R and Group RL. Intubation conditions were good or excellent in all groups. CONCLUSIONS: Additional lidocaine to rocuronium neither influences intubation condition nor accelerate the rocuronium onset, and it is cannot be viewed as an alternative for succinylcholine in rapid-sequence tracheal intubation.
Anesthesia ; Anesthetics, Local ; Fentanyl ; Humans ; Intubation* ; Lidocaine* ; Midazolam ; Neuromuscular Blockade* ; Succinylcholine ; Thiopental ; Ulnar Nerve

PURPOSE: To evaluate patient triage pattern and outcomes according to types of liver transplantation as part of a new liver transplant program developed in an East Asian country with a limited number of deceased donors. METHODS: Medical records of initial 50 liver transplantations were reviewed retrospectively. RESULTS: Twenty-nine patients underwent deceased donor liver transplantation (DDLT) and 21 patients underwent living donor liver transplantation (LDLT). Mean model for end-stage liver disease scores of recipients of DDLT and LDLT were 24.9 +/- 11.6 and 13.1 +/- 5.4, respectively (P < 0.0001). Twenty-eight patients had HCCs and 17 of them (60.7%) underwent LDLT, which was 80.9% of LDLTs. There were 2 cases of perioperative mortality; each was from DDLT and LDLT, respectively. Median follow-up was 18 months. Overall patient and graft survival rates at 6 months, 1 and 2 years were 95.7%, 93.4%, and 89.8%, respectively. There was no significant difference in survival between DDLT and LDLT. Overall recurrence-free survival rates of hepatocellular carcinoma (HCC) patients at 6 month, 1, and 2 years were 96.3%, 96.3%, and 90.3%, respectively. There was no significant difference in recurrence-free survival between DDLT and LDLT. CONCLUSION: As a new liver transplant program with limited resource and waiting list, patients with critical condition could undergo DDLT whereas relatively stable patients with HCCs were mostly directed to LDLT. We recommend a balanced approach between DDLT and LDLT for initiating liver transplant programs.
Asian Continental Ancestry Group ; Carcinoma, Hepatocellular ; Donor Selection ; Far East* ; Follow-Up Studies ; Graft Survival ; Humans ; Liver ; Liver Diseases ; Liver Transplantation* ; Living Donors ; Medical Records ; Mortality ; Retrospective Studies ; Survival Rate ; Tissue Donors ; Triage ; Waiting Lists

PURPOSE: The aim of this study was to find risk factors for early recurrence (ER) and early death (ED) after liver resection for colorectal cancer liver metastasis (CRCLM). METHODS: Between May 1990 and December 2011, 279 patients underwent liver resection for CRCLM at Korea University Medical Center. They were assigned to group ER (recurrence within 6 months after liver resection) or group NER (non-ER; no recurrence within 6 months after liver resection) and group ED (death within 6 months after liver resection) or group NED (alive > 6 months after liver resection). RESULTS: The ER group included 30 patients (10.8%) and the NER group included 247 patients (89.2%). The ED group included 18 patients (6.6%) and the NED group included 253 patients (93.4%). Prognostic factors for ER in a univariate analysis were poorly differentiated colorectal cancer (CRC), synchronous metastasis, ≥5 cm of liver mass, ≥50 ng/mL preoperative carcinoembryonic antigen level, positive liver resection margin, and surgery alone without perioperative chemotherapy. Prognostic factors for ED in a univariate analysis were poorly differentiated CRC, positive liver resection margin, and surgery alone without perioperative chemotherapy. Multivariate analysis showed that poorly differentiated CRC, ≥5-cm metastatic tumor size, positive liver resection margin, and surgery alone without perioperative chemotherapy were independent risk factors related to ER. For ED, poorly differentiated CRC, positive liver resection margin, and surgery alone without perioperative chemotherapy were risk factors in multivariate analysis. CONCLUSION: Complete liver resection with clear resection margin and perioperative chemotherapy should be carefully considered when patients have the following preoperative risk factors: metastatic tumor size ≥ 5 cm and poorly differentiated CRC.
Academic Medical Centers ; Carcinoembryonic Antigen ; Colorectal Neoplasms* ; Disease-Free Survival ; Drug Therapy ; Humans ; Korea ; Liver* ; Multivariate Analysis ; Neoplasm Metastasis* ; Recurrence* ; Risk Factors* ; Survival Analysis

It is important that extrahepatic arteries are identified precisely at the time of graft procurement. We present a case where the accessory right hepatic artery of the liver was ligated leading to postoperative liver abscess formation in the liver graft. A forty-seven-year-old female patient diagnosed with liver cirrhosis underwent orthotopic cadaveric liver transplantation due to altered mentality. The donor graft showed a variant of the hepatic artery anatomy where an accessory right hepatic artery arose from the superior mesenteric artery. This artery was accidentally transected during procurement. Since the back bleeding test using perfusion fluid was good, the artery was ligated. Postoperative abdominal computed tomography scan revealed a 6 cm low attenuating lesion in the liver. The patient underwent conservative treatment. We believe that even small accessory arteries (1 to 2 mm) should be reconstructed whenever possible to avoid postoperative complications such as liver abscess.
Arteries ; Cadaver ; Female ; Hemorrhage ; Hepatic Artery ; Humans ; Ligation ; Liver ; Liver Abscess ; Liver Cirrhosis ; Liver Transplantation ; Mesenteric Artery, Superior ; Perfusion ; Postoperative Complications ; Tissue Donors ; Transplants

Purpose: Many patients who have an acceptable living- kidney donor do not undergo transplantation because of the presence of antibodies against the donor cells resulting in a positive lymphocyte-crossmatch (LCX). Recently, the combination therapy of plasmapheresis, intravenous gamma- globulin and potent immunosuppression to induce negative conversion of LCX in patients who had positive LCX to their living donors was reported. Our institute gave these patients the combination therapy and reported the results of follow-up done 1~3 years after kidney transplantation. Methods: Eleven patients, who showed positive LCX to their living donors, underwent the conversion trials between January 1, 2002 and March 31, 2004. Combination therapy consisting of plasmapheresis, intravenous gamma globulin injection, tacrolimus, mycophenolate mofetil (MMF) and steroids was used. Plasmapheresis had been done every other day up to 6 times. Kidney transplantations were performed immediately after negative conversion was achieved. Five to ten day-courses of ATG (or OKT3) were used as an induction immunosuppression and tacrolimus, MMF, and steroids as a maintenance immunosuppression. Results: Negative conversions in ten out of eleven patients were achieved. Kidney transplantations in these 10 patients were successfully performed. No hyperacute rejection transpired, although four patients developed acute rejection, whose grafts were all rescued with steroid pulse therapy. Serum creatinine level was 1.57+/-0.12 mg/dL (mean+/-SD) during follow-up periods except for one whose graft was lost to Polyoma virus nephropathy. Conclusion: Nine of the 10 grafts are functioning well for 15~41 months after transplantations. Our results suggest that selected crossmatch positive patients can be transplanted successfully with living donor kidney allograft.
Allografts* ; Antibodies ; Creatinine ; Follow-Up Studies ; gamma-Globulins* ; Humans ; Immunosuppression ; Kidney ; Kidney Transplantation ; Living Donors ; Lymphocytes* ; Plasmapheresis* ; Polyomavirus ; Steroids ; Tacrolimus ; Tissue Donors ; Transplants

Neuronal expression of ATP-binding cassette, sub-family B (MDR/TAP), member 1 (ABCB1) has been demonstrated after brain ischemia. To investigate whether ABCB1 polymorphisms are associated with the development, risk factors (hypertension, dyslipidemia, and diabetes mellitus), severity (National Institutes of Health Stroke Scale, NIHSS), and sequelae (Modified Barthel Index, MBI) of ischemic stroke (IS), four single nucleotide polymorphisms (SNPs) of the ABCB1 gene [rs4148727, promoter, -154T>C; rs3213619, 5'-untranslation region (5'UTR), -129T>C); rs1128503, synonymous, Gly412 (C>T); rs3842, 3'UTR, A>G] were analyzed in 121 IS patients and 291 control subjects. SNPStats and SPSS 18.0 were used to obtain odds ratios (OR), 95% confidence intervals (CI), and p values. Multiple logistic regression models (codominant1, codominant2, dominant, recessive, and log-additive models) were applied to analyze the genetic data. The rs3842 SNP was weakly associated with the development of IS (p=0.020 in codominant1 model and p=0.028 in dominant model). In the analysis of clinical phenotypes, ABCB1 polymorphisms were nominally associated with hypertension (rs3213619 and rs3842, p<0.05), dyslipidemia (rs1128503, p<0.05), diabetes (rs3842, p<0.05), and NIHSS (rs4148727, p<0.05). Interestingly, rs3842 showed statistically strong association between IS with hypertension and IS without hypertension (Fisher's exact p=0.003, OR=0.11, 95% CI=0.03-0.51 in recessive model). These results suggest that the ABCB1 gene may be associated with the development and clinical phenotypes of IS in Korean population.
3' Untranslated Regions ; Academies and Institutes ; Brain Ischemia ; Dyslipidemias ; Humans ; Hypertension ; Logistic Models ; Neurons ; Odds Ratio ; Phenotype ; Polymorphism, Single Nucleotide ; Risk Factors ; Stroke

BACKGROUND: Using long-term (more than 30 years) data from a single center, this retrospective study evaluated changes of independent risk factors affecting renal allograft survival by transplant era. METHODS: Of 3,000 cases of kidney transplantation, 2,708 (90.3%), including their follow-up observations, were reviewed. Transplant era was classified according to immunosuppressive regimens as either early group (transplant serial No. 1~1,500) or recent group (transplant serial No. 1,501~3,000). RESULTS: There was a significant difference observed in pre-transplant clinical manifestations between the early and recent groups. The number of elderly recipients and donors, number of deceased donors, and cases related to pre-transplant diabetes, pre-emptive transplantation, and retransplantation were differed relative to transplant era. The short- and long-term graft survival rate of the recent group improved significantly, and the effect of human leukocyte antigen mismatching and living donor type disappeared in the recent group. Moreover, pre-emptive transplantation and retransplantation were effective only in the recent group. However, non-immunological factors such as elderly recipients and donors, and immunologic factors such as episodes of acute rejection and types of immunosuppressive regimen were persistent independent risk factors affecting graft survival rate. CONCLUSIONS: According to the retrospective survival analysis of a large number of recipients in a single center, risk factors for kidney transplant patients differed by transplant era. However, the independent risk factors associated with elderly recipients and donors (non-immunologic), and episodes of acute rejection, and types of immunosuppressive regimen (immunologic) persisted regardless of transplant era.
Aged ; Follow-Up Studies ; Graft Survival ; Humans ; Immunologic Factors ; Kidney ; Kidney Transplantation ; Leukocytes ; Living Donors ; Rejection (Psychology) ; Retrospective Studies ; Risk Factors ; Tissue Donors ; Transplantation, Homologous ; Transplants