Purpose: Hepatocellular carcinoma (HCC) is rare in HCV patients without cirrhosis, and little is known about the postoperative results of these patients. The present study compares the outcomes of cirrhotic and non-cirrhotic groups after liver resection (LR) in solitary HCV-related HCC patients and identifies risk factors for prognosis according to the presence or absence of cirrhosis in these patients. Methods: Two hundred and 7 adult hepatectomy patients with treatment-naïve solitary HCV-related HCC were identified prospectively at our institution between July 2005 and May 2019. Results: The non-cirrhotic group had better liver function than the cirrhotic group based on platelet count, liver function tests, liver stiffness measurement, and indocyanine green retention rate at 15 minutes but were older than the cirrhotic group. Consistently, noninvasive markers in the cirrhotic group were significantly higher than in the non-cirrhotic group. The cumulative disease-free survival and overall survival in the non-cirrhotic group were significantly higher than in the cirrhotic group. HCC recurrence was related to major LR and α-FP of >40 ng/mL and death was related to long hospitalization and α-FP of >40 ng/mL in multivariate analysis. Noninvasive markers and the presence of cirrhosis were not related to HCC recurrence or death in multivariate analyses. Conclusion The cirrhotic group showed poor prognosis due to poor liver function after LR compared to the non-cirrhotic group, but this was not sustained in multivariate analysis. The factors influencing HCC recurrence and death were different in the cirrhotic and non-cirrhotic groups.

Objective: Muscle depletion in patients undergoing liver transplantation affects the recipients’ prognosis and therefore cannot be overlooked. We aimed to evaluate whether changes in muscle and fat mass during the preoperative period are associated with prognosis after deceased donor liver transplantation (DDLT). Materials and Methods: This study included 72 patients who underwent DDLT and serial computed tomography (CT) scans.Skeletal muscle index (SMI) and fat mass index (FMI) were calculated using the muscle and fat area in CT performed 1 year prior to surgery (1 yr Pre-LT), just before surgery (Pre-LT), and after transplantation (Post-LT). Simple aspects of serial changes in muscle and fat mass were analyzed during three measurement time points. The rate of preoperative changes in body composition parameters were calculated (preoperative ΔSMI [%] = [SMI at Pre-LT - SMI at 1 yr Pre-LT] / SMI at Pre-LT x 100;preoperative ΔFMI [%] = [FMI at Pre-LT - FMI at 1 yr Pre-LT] / FMI at Pre-LT x 100) and assessed for correlation with patient survival. Results: SMI significantly decreased during the preoperative period (mean preoperative ΔSMI, -13.04%, p < 0.001). In the multivariable analysis, preoperative ΔSMI (p = 0.016) and model for end-stage liver disease score (p = 0.011) were independent prognostic factors for overall survival. The mean survival time for patients with a threshold decrease in the preoperative ΔSMI (≤ -30%) was significantly shorter than for other patients (p = 0.007). Preoperative ΔFMI was not a prognostic factor but FMI increased during the postoperative period (p = 0.009) in all patients. Conclusion A large reduction in preoperative SMI was significantly associated with reduced survival after DDLT. Therefore, changes in muscle mass during the preoperative period can be considered as a prognostic factor for survival after DDLT.

Purpose: Little is known about liver resection (LR) in hepatocellular carcinoma (HCC) patients older than 75 years of age. This study aimed to compare the postoperative and long-term outcomes of hepatectomy in this patient population according to operation period. Methods: This study included 130 elderly patients who underwent LR for solitary treatment-naïve HCC between November 1998 and March 2020. Group 1 included patients who underwent LR before 2016 (n = 68) and group 2 included those who underwent LR during or after 2016 (n = 62). Results: The proportion of major LR, anatomical LR, and laparoscopic LR (LLR) in group 1 was significantly lower than those in group 2. Also, the median operation time, amount of blood loss, hospitalization length, rates of intraoperative blood transfusion, and complications in group 2 were less than those in group 1. In the subgroup analysis of group 1, high proteins induced by vitamin K absence or antagonist-II, long hospitalization, and LLR were closely associated with mortality. In the subgroup analysis of group 2, however, none of the factors increased mortality. Nevertheless, the presence of tumor grade 3 or 4 and the incidence of microvascular invasion were higher in group 1 than in group 2, and the disease-free survival and overall survival were better in group 2 than in group 1 because of minimized blood loss and quicker recovery period by increased surgical techniques and anatomical approach, and LLR. Conclusion LR in elderly HCC patients has been frequently performed recently, and the outcomes have improved significantly compared to the past.

Background/Aims: Biliary strictures remain one of the most challenging aspects after living donor liver transplantation (LDLT). The aim of this study was to assess long-term outcome of endoscopic treatment of biliary strictures occurring after LDLT and to identify risk factors of recurrent biliary strictures following endoscopic retrograde biliary drainage (ERBD) in LDLT. Methods: A total of 1,106 patients underwent LDLT from May 1995 to May 2014. We compared the risk factors between patients with and without recurrent biliary strictures. Results: Biliary strictures developed in 24.0% of patients. Technical success rate of ERBD for biliary stricture after LDLT was 66.2% (145/219). Among 145 patients managed by endoscopic drainage, stricture resolution occurred in 69 with median duration of stent indwelling of 13.6 months (range, 0.5 to 67.3 months), and stricture recurrence was seen in 20 (21.3%) out of 94. The median recurrence-free duration after final endoscopic success was 13.1 months (range, 0.5 to 67.3 months). Older donor age (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03 to 1.17; p=0.004) and non-B, non-C liver cirrhosis (HR, 5.10; 95% CI, 1.10 to 25.00; p=0.043) were associated with higher recurrence of biliary stricture. Conclusions Long-term stricture resolution rate after ERBD insertion for biliary stricture occurring after LDLT was 73.4%. Clinicians should pay careful attention during following-up to decide when to remove ERBD in patients who have factors associated with recurrent biliary strictures.

PURPOSE: Laparoscopic major liver resection (major LLR) remains a challenging procedure because of the technical difficulty. Several significant technical innovations have been applied in our center since 2012. They include routine application of bipolar electrocautery, initiation of temporary increase of intra-abdominal pressure during bleeding events from veins to balance the central venous pressure, and use of temporary inflow control of the Glissonean pedicle. This study evaluated the impact of these technique modifications in patients with major LLR. METHODS: Between January 2004 and February 2015, a total of 606 patients underwent LLR at Samsung Medical Center in Seoul, Korea. Major LLR was employed in 233 cases. All major LLR procedures were anatomical resections performed with a totally laparoscopic approach. We compared surgical parameters of right hepatectomy (RH), left hepatectomy (LH), and right posterior sectionectomy (RPS) before and after 2012. RESULTS: Open conversion rates of RH and LH and estimated blood loss in RPS significantly decreased after 2012. The postoperative complication rate of major LLR was 12.7% and was similar before and after 2012. Bile leakage was the most common complication (3.2%). CONCLUSION: The modifications of surgical techniques resulted in good outcomes for laparoscopic major LLR. We recommend routine application of these techniques to improve outcomes, especially in patients requiring major liver resection.
Bile ; Central Venous Pressure ; Electrocoagulation ; Hemorrhage ; Hepatectomy ; Humans ; Korea ; Laparoscopy ; Learning Curve ; Liver* ; Minimally Invasive Surgical Procedures ; Postoperative Complications ; Seoul ; Veins

PURPOSE: The purpose of this study was to describe the long-term effects of stenting in patients with hepatic venous outflow obstruction (HVOO), who underwent living donor liver transplantation (LDLT). METHODS: Between January 2000 and December 2009, 622 adult patients underwent LDLT at our hospital, and of these patients, 21 (3.3%) were diagnosed with HVOO; among these patients, 17 underwent stenting. The patients were divided into early or late groups according to the time of their HVOO diagnoses (cutoff: 60 days after liver transplantation). RESULTS: The median follow-up period was 54.2 months (range, 0.5–192.4 months). Stent insertion was successful in 8 of 10 patients in the early group and 6 of 7 in the late group. The 5-year primary patency rates were 46% and 20%, respectively. In both groups, patients with recurrent HVOO at the beginning showed kinking confirmed by venography. Patients who carried their stents for more than 3 years maintained long-term patency. There was no significant difference in spleen size between groups; however, when the groups were compared according to whether they maintained patency, spleens tended to be smaller in the patency-maintained group. CONCLUSION: Unlike stenosis, if kinking is confirmed on venography, stenting is not feasible in the long term for patients with LDLT.
Adult ; Budd-Chiari Syndrome ; Constriction, Pathologic ; Diagnosis ; Follow-Up Studies ; Hepatic Veins* ; Humans ; Liver Transplantation* ; Liver* ; Living Donors* ; Phlebography ; Spleen ; Stents*

PURPOSE: Infection remains the main cause of morbidity and mortality in liver transplantation (LT) recipients; however infection is notoriously difficult to diagnose because its usual signs and symptoms of infection may be masked or absent. This study comprises an analysis of bacterial infections in the early period after LT. METHODS: This is a study of 129 adults who underwent LT from January 2013 to December 2013, and it includes patients who were followed daily from the day of transplantation to 1-week posttransplantation using bacteriological cultures of blood, urine, sputum, and drained ascites. RESULTS: The following factors were significantly different between the positive and negative culture groups: living donor LT vs. deceased donor LT (odds ratio [OR], 3.269; P = 0.003), model for end-stage liver disease score (OR, 4.364; P < 0.001), and Child-Pugh classification (P = 0.007). Neither positive culture nor negative culture was associated with infection within 4 weeks of surgery (P = 0.03), and most events were due to surgical complications (75%). CONCLUSION: Since the full effect of immunosuppression is not yet present during the first month after LT, we suggest that the number of bacterial culture test could be reduced such that they are performed every other day depending on patient's situation.
Adult ; Ascites ; Bacterial Infections* ; Classification ; Culture Techniques ; Humans ; Immunosuppression ; Liver Diseases ; Liver Transplantation* ; Liver* ; Living Donors ; Masks ; Mortality ; Sputum ; Tissue Donors

PURPOSE: Although few hepatectomy patients develop unexpected early diffuse and multinodular recurrence in the remnant liver, the prognosis in such cases is often dismal. The aim of this study was to evaluate the risk factors of early disseminated multinodular hepatocellular carcinoma (HCC) recurrence within 3 months after liver resection for solitary HCC. METHODS: Eighty-four patients who were diagnosed with recurrent HCC within 3 months after hepatectomy for solitary HCC were retrospectively reviewed. Disseminated HCC recurrence was defined as more than 10 tumors in both lobes and total tumor size >10 cm. RESULTS: Preoperative α-FP level, incidence of poor tumor grade, and presence of portal vein tumor thrombosis were higher in the patients with disseminated HCC recurrence than in those without disseminated HCC recurrence (P < 0.05). Multivariate analysis showed that α-FP >1,000 ng/dL was a predisposing factor of disseminated HCC recurrence within 3 months after liver resection. The overall survival rate for patients without disseminated HCC recurrence was higher than that for patients with disseminated HCC recurrence (P < 0.001). CONCLUSION: Early disseminated multinodular HCC recurrence in hepatectomy patients was associated with preoperative α-FP >1,000 ng/dL. Such patients should be frequently evaluated for the early detection of recurrent HCC for early intervention.
Carcinoma, Hepatocellular* ; Causality ; Early Intervention (Education) ; Hepatectomy ; Humans ; Incidence ; Liver* ; Multivariate Analysis ; Portal Vein ; Prognosis ; Recurrence* ; Retrospective Studies ; Risk Factors ; Survival Rate ; Thrombosis

Clinical outcomes of living donor liver transplantation (LDLT) for hepatocellular carcinoma (HCC) in patients with multiple myeloma (MM) have not been established in terms of HCC recurrence and MM deterioration after LDLT. A 51-year-old man with chronic hepatitis B was diagnosed with HCC and MM. Since the patient also had decompensated liver cirrhosis (LC), he underwent LDLT prior to autologous peripheral blood stem cell transplantation (PBSCT) to prevent fulminant hepatitis due to HBV reactivation. The patient received Epstein-Barr virus prophylaxis and a triple immunosuppressive regimen of tacrolimus, everolimus, and steroid after LDLT. Autologous PBSCT was performed 7 months after LDLT. He showed a complete response to treatment of MM without post-LT complications or HCC recurrence. In conclusion, LDLT could be adapted for treatment of MM patients with combined HCC and decompensated LC because it is an effective strategy of preventing HBV reactivation and HCC recurrence after induction therapy of MM.
Carcinoma, Hepatocellular* ; Everolimus ; Hepatitis B, Chronic ; Hepatitis* ; Herpesvirus 4, Human ; Humans ; Liver Cirrhosis* ; Liver Transplantation* ; Liver* ; Living Donors* ; Middle Aged ; Multiple Myeloma* ; Peripheral Blood Stem Cell Transplantation ; Recurrence ; Tacrolimus

PURPOSE: Preoperative F-18-fluoro-2-deoxy-glucose positron emission tomography (18F-FDG PET) imaging results appear to predict tumor recurrence and patient survival. The present study compared outcomes between PET-positive and PET-negative groups with HBV-related hepatocellular carcinoma (HCC) who underwent curative hepatectomy and assessed the prognostic value of positive PET-CT for HCC recurrence and death. METHODS: This study included patients who underwent liver resection of solitary HCC between 2007 and 2014 based on preoperative radiological images. There were 133 patients in the PET-positive group and 93 in the PET-negative group. RESULTS: There were no statistically significant differences in baseline, perioperative, or pathologic characteristics between the 2 groups except HBsAg titer, tumor size, and presence of bile duct tumor thrombi. Multivariate analysis showed that tumor size >3.5 cm and HBsAg titer >1,000 cutoff index were predisposing factors of positive PET-CT. Disease-free survival and overall survival rate at 1, 3, and 5 years were 76.3%, 64.4%, 60.3% and 96.8%, 91.1%, 85.1% in the PET-negative group, respectively, compared with 70.7%, 62.2%, 58.9% and 98.5%, 97.0%, 97.0% in the PET-positive group (P = 0.547 and P = 0.046). Multivariate analysis showed that positive PET-CT was closely associated with increased patient survival, but was not related to HCC recurrence. CONCLUSION: These results suggest that positive PET findings are not a predisposing factor for recurrence of HBV-related HCC patients, but appear to be associated with improved patient survival. Further prospective studies are needed to confirm the prognostic value of 18F-FDG PET in these patients.
Bile Ducts ; Carcinoma, Hepatocellular ; Causality ; Disease-Free Survival ; Electrons* ; Fluorodeoxyglucose F18 ; Hepatectomy* ; Hepatitis B Surface Antigens ; Hepatitis B virus ; Humans ; Liver ; Multivariate Analysis ; Positron-Emission Tomography* ; Prognosis* ; Prospective Studies ; Recurrence ; Survival Rate