Search

OBJECTIVES Our goal was to compare the oncological outcomes and efficacy between minimally invasive thymectomy (MIT) and open thymectomy (OT) in patients with early or locally advanced thymoma using a multicentre study database. METHODS We retrospectively collected data from 1,239 patients who underwent thymectomy between January 2000 and December 2013, as recorded in the database of the Korean Association for Research on Thymus. We compared the postoperative outcomes of the MIT and OT groups using unmatched and propensity score (PS) matched data. RESULTS We excised the thymoma using MIT and OT in 455 and 784 patients, respectively. We matched 378 patients with Masaoka-Koga stage I or II thymoma by their PS. The operative time, duration of hospital stay and complications were significantly shorter in the MIT group than in the OT group (all P CONCLUSIONS Compared with OT, MIT was associated with shorter operative times, shorter durations of hospital stay and fewer complications. Long-term survival, recurrence-free survival and complete resection were not significantly different between the OT and MIT groups. Our findings may help physicians track the progress of patients with early or locally advanced thymomas and design treatment plans for them.

We describe the occurrence of acute type A aortic dissection in a patient with situs inver-sus totalis. A 37-year-old man presented to the emergency department with acute chest pain. Initial chest X-ray findings showed a right-sided heart and a left-sided liver. Con-trast-enhanced computed tomography revealed a Stanford type A acute aortic dissection, aortic root dilatation, and situs inversus totalis. All of the thoracic structures were mirror-im-age reversed and an abnormal coronary artery was observed. The Bentall operation was performed. This report demonstrates that computed tomography and echocardiography were useful for understanding the anatomy and the presence or absence of concurrent anomalies in a patient with situs inversus totalis. The patient’s postoperative course was uneventful.

The prognostic significance of tumor size in thymic epithelial tumors (TETs) has not been fully evaluated. We aimed to clarify the prognostic value of tumor size in limited-stage and advanced-stage TETs.Clinical records of patients with completely resected TETs were retrospectively collected from 4 tertiary centers between January 2000 and February 2013. Information on the Masaoka-Koga stage was available for 1215 patients (M-K group), and 433 patients were classified according to the eighth edition of the Tumor-Node-Metastasis staging system (TNM group). Limited-stage and advanced-stage TETs were defined according to whether they were confined within the surrounding fatty tissues without invasion. The optimal cutoff value was selected using a maximally selected log-rank statistic.The median tumor size was 6.0 ± 2.8 cm in the M-K group and 6.5 ± 3.0 cm in the TNM group. In the multivariable analysis, tumor size had a significant effect on both overall survival (P = .003) and recurrence-free survival (P .001) for limited-stage tumors (M-K stage I or II or TNM stage I), but not for advanced-stage tumors (M-K stage III or IV or TNM stage II-IV; P = .349 for overall survival and P = .439 for recurrence-free survival). The optimal cutoff value for tumor size was5.5 cm for both overall survival and recurrence-free survival in limited-stage TETs.Tumor size is an independent prognostic factor in patients with completely resected limited-stage TETs and a cutoff value5.5 cm might help clinicians enact proper treatment strategies and surveillance.

This essay examines Catholic vestments on the English stage from the early Reformation through Shakespeare. The changing meaning, status, and usage of Catholic vestments, which crossed the boundary from sacred religious property to secular theatrical costume, enabled the diverse theatrical manipulation of the garments to build on and relieve contemporary social anxiety about Catholicism. This, in turn, demonstrates the self-contradictory attitudes of many early modern English subjects toward Catholicism, theatricality, and sexuality. The discussion begins with the vestiarian controversies caused by the radical Protestants' stubborn resistance to state control over what to wear in Reformed churches. This controversy can be elucidated by a look at vestment rentals and sales before and after the Reformation. The economic value and cultural history of vestments as well as the related religious polemic played a crucial role in determining where vestments belonged physically and metaphorically. The discussion then focuses on several plays that stage vestments during and after the Reformation and explores what they reflected and represented. From the effort to keep Catholic vestments as the symbol of sacred authority to the strategic movement to reverse their meaning to secularized Catholic hypocrisy, struggles to control the meaning invested in the liturgical Catholic vestments were represented, embodied, and enacted in early modern theater history as well as in the plays staged in the period. ********** IN post-Reformation England, Catholic clerical vestments, newly divested of their sacred authority, were sold to theaters as costumes. Ann Rosalind Jones and Peter Stallybrass suggest that the journey of religious garments from church to theater represented "a series of translations in which a sacred garment from the theater of God came to represent a 'heathen' religion on the secular stage." (1) With the relatively rapid transitions of state religion under Edward VI, Mary, and Elizabeth, Catholic ecclesiastical clothes circulated from altars to stage and stage to altars, ensuring the separation of sacred meaning from these formerly sacred signifiers. Clerical robes on commercial stages might remind theater audiences of their original religious aura as much as the same robes in the pulpit might remind churchgoers of their commercial use in public theaters. The transfer of vestments to theaters in sixteenth-century England was not motivated solely by religious change. Churches sold or rented out vestments and accessories not only to serve theatrical enterprise, but also to compensate for the financial shortages created by the decrease in church-sponsored plays and the costs of redecorating churches previously full of Catholic furnishings and ornaments. Liza Picard observes that in one case, "all the old copes and vestments, with the alb, fetched 5 [pounds sterling] 10s, so the church made an overall profit from the changeover." (2) Drama historians point out that the often luxurious Catholic clothing, like all clothing used for costuming actors, was a considerable investment for theater companies: according to Andrew Gurr, the impresario Philip Henslowe "invested rather more money in apparel for the players than in playbooks, and far more than in stage properties." (3) In his diary, Henslowe recorded not only the expenses for new costumes but also the payments for clothes-keepers, tailors, mercers, milliners, lacemakers, and a "sylke man." (4) Furthermore, the acquisition of particular clothing often triggered new characters and new plays: according to Jean MacIntyre, outlays for costumes often influenced performance repertory. (5) Garments now superfluous to the needs of the church became vital new properties for English drama. The changing meaning, status, and usage of vestments enabled theatrical use of the garments to build on and relieve contemporary social anxiety about Catholicism. This, in turn, demonstrates the self-contradictory attitudes of many early modern English subjects toward Catholicism, theatricality, and sexuality. …

Purpose: The purpose of this study was to identify the effects of thermotherapy on abdominal distension and pain during colonoscopy. Methods: This study used a nonequivalent control group and a non-synchronize design. Twenty-nine participants were assigned in an experimental group and 29 in the control group. For the experimental group, electronic heating pad was applied before test throughout the entire procedure. Results: Abdominal distension and total time required for colonoscopy significantly were lower in the experimental group than those in the control group. Conclusion: The results suggest that thermotherapy can be effective to improve abdominal distension and colonoscopy time in patients with colonoscopy. Therefore, thermotherapy can be recommended for those patients undergoing of colonoscopy.

The purpose of this study is to suggest a development model of English literature database, which will be widely available for narrative creation and editing in digital environment. The database will be allowed to assist effective recycling of various motifs prompted by existing literary works. This paper suggests how to build a story database of English literature by demonstrating a motif abstracting model with Hamlet originally written by William Shakespeare. It is hoped that this study will contribute to producing quality contents of storytelling and also give English literature experts chances of collaboration in the development of digitalized contents. Key Words : English literature, story, story database, motif, hamlet, storytelling, convergence Received 20 July 2015, Revised 24 August 2015Accepted 20 September 2015Corresponding Author: Dong-il Shin(Chung-Ang University) Email: shin@cau.ac.krⒸ The Society of Digital Policy & Management. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is ISSN: 1738-1916 properly cited.

Background Although the strongest benefit of a concomitant Maze procedure during mitral valve repair is the obviation of the need for anticoagulation therapy, the risk of thromboembolism without anticoagulation therapy has not been evaluated. Methods A total of 362 consecutive patients (aged 52.2 ± 13.8 years, 180 females) who underwent the Maze procedure combined with mitral valve repair between 1997 and 2012 were evaluated. Anticoagulation therapy was discontinued after 6 months if synchronous atrial contraction was maintained in the absence of further risks of thromboembolism. Results The median follow-up period was 5.4 years (interquartile range, 2.9 to 9.6 years). Late atrial fibrillation (AF) occurred in 62 patients (17.1%). The 5-year freedom from AF off anti-arrhythmic drugs was 82.6% ± 2.3%. In 96 patients (26.5%), warfarin was administered in the late period (>6 months), and of them, 54 patients (14.9%) were maintained with warfarin therapy until the end of the follow-up. Patients receiving warfarin therapy were older ( p = 0.030), had longer AF duration ( p = 0.012), and had rheumatic valvulopathy more frequently ( p = 0.003) compared with those not receiving warfarin. Overall, patients were followed up off the warfarin therapy for 1,577 patient-years, during which there were 4 cases of stroke or transient ischemic accident and 21 late deaths. The linearized rates of thromboembolic event and death without warfarin therapy were 0.06% and 0.12% per patient-year, respectively, and these rates were not significantly different from those receiving warfarin therapy. Conclusions Adopting appropriate selection criteria for discontinuing anticoagulation therapy, the majority of patients receiving concomitant mitral repair and the Maze procedure can discontinue warfarin with excellent long-term safety profiles.

Purpose This study reviewed the past and present status of liver transplantation (LT) and outlooks for the future of LT in Korea. Method The first LT in Korea was successfully performed using a deceased donor graft in 1988. Pediatric and adult living donor liver transplantations (LDLTs) were initiated in 1994 and 1997, respectively. From 1988 to 2013, 10,581 LTs were performed at 40 centers, whereas LDLT accounted for 76.5% of all LTs. Results In the early 1990s, the deceased organ donation rate was less than 1.5 per million population (PMP) per year, but it increased to 5 PMP beginning in 2008. Despite the increasing number of deceased donor liver transplantations (DDLTs), high prevalence of hepatitis B virus (HBV)-induced cirrhosis and hepatocellular carcinoma (HCC) has provoked persistent performance of adult LDLT with technical advancement including middle hepatic vein (MHV) reconstruction of right lobe graft and dual graft LDLT with 1 nationwide donor mortality. Conclusion The number of LTs in Korea in 2010 was 23.2 PMP (1042 LTs/45 million population), lower than 23.5 PMP of Spain, but higher than 20 PMP of the United States. However, future LT numbers may decrease because of lowering the HBV carrier rate (neonatal HBV universal vaccination began in 1992), new potent anti-HBV agents, and lowest birth rate (1.22 children per family) with a decrease of potential live donors.

Background and objectives The purpose of the present study was to investigate the advantages and disadvantages of verifying genetic abnormalities using array comparative genomic hybridization (a-CGH) immediately after diagnosis of congenital heart disease (CHD). Methods Among neonates under the age of 28 days who underwent echocardiography from January 1, 2014 to April 30, 2016, neonates whose chromosomal and genomic abnormalities were tested using a-CGH in cases of an abnormal finding on echocardiography were enrolled. Results Of the 166 patients diagnosed with CHD, 81 underwent a-CGH and 11 patients (11/81, 13.5%) had abnormal findings on a-CGH. 22q11.2 deletion syndrome was the most common (4/11, 36.4%). On the first a-CGH, 4 patients were negative (4/81, 5%). Three of them were finally diagnosed with Williams syndrome using fluorescent in situ hybridization (FISH), 1 patient was diagnosed with Noonan syndrome through exome sequencing. All of them exhibited diffuse pulmonary artery branch hypoplasia, as well as increased velocity of blood flow, on repeated echocardiography. Five patients started rehabilitation therapy at mean 6 months old age in outpatient clinics and epilepsy was diagnosed in 2 patients. Parents of 2 patients (22q11.2 deletion syndrome and Patau syndrome) refused treatment due to the anticipated prognosis. Conclusions Screening tests for genetic abnormalities using a-CGH in neonates with CHD has the advantage of early diagnosis of genetic abnormality during the neonatal period in which there is no obvious symptom of genetic abnormality. However, there are disadvantages that some genetic abnormalities cannot be identified on a-CGH.

Background We previously showed that ringed polytetrafluoroethylene (PTFE) grafts combined with small allograft patches showed high patency rates similar to those of iliac vein grafts and therefore that they can be used for middle hepatic vein (MHV) reconstruction. Although such use of PTFE graft showed high patency rates, its long-term safety regarding infection and other types of complications were not presented. In this study, we investigated the actual risk of complications directly associated with PTFE graft interposition for MHV reconstruction. Methods During the study period of 30 months, we performed 215 cases of adult living-donor liver transplantation with modified right lobe graft and PTFE grafts. We classified the potential complications directly associated with PTFE graft interposition as infectious and surgical complications. The medical records of study patients were retrospectively reviewed. Results MHV graft patency rate was 76.3% at 6 months and 36.7% at 12 months. Their 1-year graft and patient survival rates were 92.6% and 93.5%, respectively. The 1-year actual incidences of infectious complication and surgical complication were near zero and 1 case (0.5%), respectively. In 1 recipient, the PTFE graft penetrated into the stomach wall 6 months after transplantation, but the patient did not complain of any specific symptoms. The PTFE graft was removed with the use of laparotomy, and the patient recovered uneventfully. Conclusions Although the incidence of PTFE graft–associated complication rate is very low, we suggest that it is necessary to closely monitor the PTFE graft, because unexpected complications can happen during long-term follow-up.

Purpose Mycophenolate mofetil (MMF) is frequently used after liver transplantation (OLT). Mycophenolic acid (MPA) metabolites are eliminated primarily via the kidneys. If renal function declines, clearance is significantly impaired. The aim of this study was to reveal the renal function-dependent changes of MPA level in stable adult OLT recipients receiving MMF monotherapy. Methods Sixty-five OLT recipients were selected from our OLT database of >3500 cases. All had undergone MMF monotherapy with a daily MMF dose of 1000 mg or 1500 mg for more than 2 years, primarily because they could not tolerate calcineurin inhibitors. Their clinical profiles, including MPA therapeutic drug monitoring (TDM) and renal function, were analyzed as a cross-sectional study. Results For the group treated with 1000 mg MMF ( n = 40), the 12-hour MPA trough level was 1.20 ± 0.35 μg/mL with serum creatinine (Cr) level ≤1.4 mg/dL in 13 patients; it was 2.78 ± 1.19 μg/mL with Cr >1.4 mg/dL in 16 patients not undergoing hemodialysis and 3.83 ± 0.87 μg/mL in 11 patients undergoing hemodialysis ( P n = 25), the MPA trough level was 2.23 ± 0.99 μg/mL with Cr ≤1.4 mg/dL in 6 patients; it was 2.81 ± 0.99 μg/mL with Cr >1.4 mg/dL in 18 patients not undergoing hemodialysis and 3.5 μg/mL in 1 patient undergoing hemodialysis ( P = .21). Conclusions Considering the potential therapeutic range of MPA, the suggested MMF dosage for Korean adult OLT recipients requiring hemodialysis may be set around 1000 mg per day. We suggest adjusting the MMF dosage on an individualized basis according to the results of MPA TDM, particularly for patients with markedly impaired renal function.

We present a case of a 55-year-old woman who complained of chest pain at rest. A mass was detected adjacent to her left atrium. The mass was completely excised, and a pathologic examination revealed it to be a schwannoma. Schwannomas are tumors that originate in the nerve sheath and are rarely detected in the heart. Here, we describe a rare case of primary schwannoma of the left atrium.

Background Long-term prognosis of liver transplantation (LT) for hepatocellular carcinoma (HCC) with macroscopic bile duct tumor thrombus (BDTT) has not been well assessed. This study intended to analyze the post-transplantation outcomes in patients who had HCC with macroscopic BDTT. Methods A retrospective study was performed with 14 patients who underwent LT for HCC with BDTT (0.7%) after selection from an institutional database of 2052 adult LT cases. Results Types of LT were living donor LT in 13 and deceased donor LT in 1. The extents of BDTT were Ueda type 1 in 4, type 2 in 3, and type 3 in 7. Milan criteria were met in 8 (57.1%). Concurrent bile duct resection was performed in 7 (50%). Mean model for end-stage liver disease score was 18.7 ± 4.9. Mean graft-recipient weight ratio was 1.2 ± 0.3. There was one case of perioperative mortality and one case of HCC-unrelated late mortality. Cumulative HCC recurrence rates were 15.4% at 1 year, 46.2% at 3 years, and 46.2% at 5 years. Overall patient survival rates were 92.9% at 1 year, 57.1% at 3 years, and 50% at 5 years. Univariate risk factor analyses revealed that only macrovascular invasion was a significant risk factor for HCC recurrence (P = .019). Conclusions The results of this study revealed that LT for HCC with macroscopic BDTT has a high risk of post-transplantation HCC recurrence; therefore, further large-volume studies are necessary to elucidate the risk factors.

Background: Although a residual intimal tear may contribute to the dilatation of the descending aorta following surgical repair of acute type I aortic dissection (AD), its causal relationship has not been elucidated by clinical data due to the limited resolution of imaging modalities. Methods: This study enrolled 41 patients (age, 55.2±11.9 years) who were evaluated with dual-source computed tomography (CT) imaging of the whole aorta in the setting of the surgical repair of acute type I AD. Logistic regression models were used to determine the predictors of a composite of the aortic aneurysm formation (diameter ＞55 mm) and rapid aortic expansion (＞5 mm/yr). Results: On initial CT, a distal re-entry tear was identified in 9 patients. Two patients failed to achieve proximal tear exclusion by the surgery. Serial follow-up CT evaluations (median, 24.6 months; range, 6.0 to 67.2 months) revealed that 14 patients showed rapid expansion of the descending aorta or aortic aneurysm formation. A multivariate analysis revealed that the residual intimal tear (odds ratio [OR], 4.31; 95% confidence interval [CI], 1.02 to 19.31) and the patent false lumen in the early postoperative setting (OR, 4.64; 95% CI, 0.99 to 43.61) were predictive of the composite endpoint. Conclusion: The presence of a residual intimal tear following surgery for acute type I AD adversely influenced the expansion of the descending aorta.

Most cases of Ewing's sarcoma are reported in the bone, and extraosseous Ewing's sarcoma is an extremely rare disease. Here, we report a rare case of primary pulmonary Ewing's sarcoma in a patient with hemoptysis. The patient underwent right upper lung lobe lobectomy with adjuvant chemotherapy and radiation therapy and has been free of recurrent disease for 4 years.

Background Liver perfusate (LP) lymphocytes show unique subsets compared with peripheral blood (PB) lymphocytes. LP natural killer (NK) and NKT cells may display unique cytotoxicity and cytokine production, thus leading to distinct roles in liver transplantation. In this study, we sought to evaluate the functions of graft perfusate NK and NKT cells in clinical liver transplantation. Methods The living donor right lobe graft was initially washed with 1 L of histidine-tryptophan-ketoglutarate solution to collect the perfusate. We also collected donor PB. Lymphocytes separated by the Ficoll-Hypaque density gradient method underwent immunophenotyping using multicolor flow cytometry. To assess cytokine secretion, we performed the enzyme-linked immunosorbent assay. Results There were more NK and NKT cells in LP confirming previous reports. In particular, CD56 bright CD16 low NK cells accounted for approximately 50% of total NK cells compared with 5% to 10% among PB NK cells. In response to cytokine stimulation LP NK cells produce tumor necrosis factor–α at different levels and less interleukin-10 compared with PB NK cells. The major source of interferon-γ production upon stimulation with liver caner cells were CD56 dim NK cells and CD56 − CD3 − cells rather than NKT or T cells. Unlike PB NK cells, LP CD56 bright CD16 low NK cells along with CD56 dim CD16 high NK cells and NKT cells were efficient killers against Korean liver cancer cells. Conclusion LP NK and NKT cells showed unique functions in cytotoxicity and cytokine production.

Purpose The aim of the present study was to examine the clinical course of nonvascular hepatic ischemia following adult living donor liver transplantation (LDLT). Methods This retrospective study reviewed the medical records of 1782 patients who underwent LDLT from January 2003 to September 2010. Nine subjects (0.5%) suffered idiopathic hepatic parenchymal infarcts (IHPI) classified according to the morphology and extent of the infarcted area as peripheral or central. Results Increased levels of liver enzymes were observed in all IHPI patients. Liver cell damage closely correlated with the extent of the infarcted area. Most patients with peripheral-type IHPI showed favoarable spontaneous recovery, occasionally requiring liver support with plasmapheresis or a prolonged period. By contrast, 2 patients with central-type IHPI died due to progressive expansion of the infarcted area with subsequent graft failure. Conclusions In the present study the incidence of IHPI following LDLT was 0.5%. The severity of the infarct depended upon its location and size; central-type IHPI showed a worse prognosis. Thus, special attention should be paid to patients showing a central-type infarction.

Neurodevelopmental disorders include a wide range of diseases such as autism spectrum disorders and mental retardation. Mutations in several genes that regulate neural development and synapse function have been identified in neurodevelopmental disorders. Interestingly, some affected genes and pathways in these diseases are associated with the autophagy pathway. Autophagy is a complex, bulky degradative process that involves the sequestration of cellular proteins, RNA, lipids, and cellular organelles into lysosomes. Despite recent progress in elucidating the genetics and molecular pathogenesis of these disorders, little is known about the pathogenic mechanisms and autophagy-related pathways involved in common neurodevelopmental disorders. Therefore, in this review, we focus on the current understanding of neuronal autophagy as well as recent findings on genetics and the roles of autophagy pathway in common neurodevelopmental disorders.

ABO-incompatible (ABOi) adult living donor liver transplantation (ALDLT) is a feasible therapeutic option for countries with a scarcity of deceased donors. This report presents our initial experiences in ABOi ALDLT in 10 patients between December 2008 and September 2009. The mean age of recipients was 48.5 ± 5.7 years (range, 40–54 years). The mean Model for End-stage Liver-Disease score was 13.9 ± 4.0 (range, 9–22). All patients were administered preoperative rituximab once and plasma exchanges according to the hemagglutinin titer. The spleen was preserved in all cases. For local infusion therapy, hepatic arterial infusion was performed in 9 patients and portal vein infusion in 1 subject. The 10 patients experienced no in-hospital mortality. At a mean follow-up period of 31.8 ± 2.9 months (range, 4.1–34.9 months), 1 patient has died (postoperative month 4 due to sepsis following a biliary stricture. The 3-month patient and graft survivals were 100%, and 1- and 2-year survivals, 90.0%. There was no episode of antibody-mediated rejection. The promising results of our initial experience may have been due to the use of preoperative rituximab and the good preoperative conditions of the patients.

Objectives For early-stage thymoma, complete thymectomy has classically been regarded as the standard treatment protocol. However, several studies have shown that limited thymectomy may be an alternative treatment option for thymoma. This study compared perioperative outcomes, survival, and recurrence rates between patients undergoing limited thymectomy and complete thymectomy. Materials and methods Between January 2000 and December 2013, a total of 762 patients underwent thymectomy for stage I or II thymomas at four institutions participating in the Korean Association for Research on the Thymus. Patients were divided into two groups: limited thymectomy group (n = 295) and complete thymectomy group (n = 467). Comparative clinicopathological, surgical, and oncological features were reviewed retrospectively. Results The median follow-up time was 49 months (range: 0.2–189 months). A propensity score-matching analysis, based on seven variables (age, sex, surgical approach, tumor size, WHO histological type, Masaoka-Koga stage, and adjuvant radiotherapy), was performed using 141 patients selected from each group. The 5- and 10-year freedom-from-recurrence rates in the limited thymectomy group were 96.3% and 89.7%, respectively, and those in the complete thymectomy group were 97.0% and 85.0%, respectively. No significant differences in these rates were observed between groups (p = 0.86). A multivariate Cox regression analysis showed that overall survival and freedom-from-recurrence rates did not significantly differ by surgery extent (p = 0.27, 0.66, respectively). Perioperative outcomes were better in the limited thymectomy group. Conclusion Limited thymectomy was not inferior to complete thymectomy with respect to recurrence, and had better perioperative outcomes. Limited thymectomy may be a viable treatment option for early-stage thymoma.

Background: Lung cancer patients with idiopathic pulmonary fibrosis (IPF) are at a high risk of requiring lung resection. The optimal surgical strategy for these patients remains unclear. This study aimed to compare the clinical results of a sublobar resection versus a lobectomy or more extensive resection for lung cancer in patients with IPF. Methods: From January 1995 to December 2012, 80 patients with simultaneous non-small cell lung cancer and IPF were treated surgically at Asan Medical Center. Predictors of recurrence-free survival and overall survival were evaluated in the series. Results: Lobectomy or more extensive resection of the lung (lobar resection group) was performed in 65 patients and sublobar resection (sublobar resection group) was carried out in 15 patients. The sublobar resection group showed fewer in-hospital mortalities than the lobar resection group (6.7% vs . 15.4%; P=0.68). For late mortality after lung resection, cancer-related deaths were not significantly different in incidence between the two groups (55.6% vs . 30.6%; P=0.18). Recurrence-free survival after lung resection was significantly greater in the lobar than in the sublobar resection group (P=0.01). However, overall survival after lung resection was not significantly different between the two groups (P=0.05). Sublobar resection was not a significant predictive factor for overall survival (hazard ratio =0.50; 95% CI: 0.21–1.15; P=0.10). Conclusions: Although not statistically significant, a sublobar resection results in less in-hospital mortality than a lobar resection for lung cancer patients with IPF. There is no significant difference in overall survival compared with lobar resection. A sublobar resection may be another therapeutic option for lung cancer patients with IPF.

Purpose To estimate the effect of splenic artery embolization (SAE) on blood flow in orthotopic liver transplantation (OLT) recipients with splenic artery steal syndrome (SASS) based on changes in caliber of related arteries upon serial computed tomography (CT) scans. Methods Between 2004 and 2007, nine OLT recipients with SASS underwent SAE. They had CT scans before and after SAE: short-, mid-, and long-term, ie, approximately 1 week, 1 month, and 1 year, respectively. The diameters of the celiac axis (CA), common hepatic artery (CHA), and splenic artery (SA) were measured with arterial phase of each CT scan and the ratios of SA to CHA diameter (SA/CHA) calculated to analyze their changes during the follow-up period. Results The diameters of celiac axis, CHA, and SA and SA/CHA changed most rapidly during the short-term period. The CHA diameter significantly increased short-term post-SAE by CT and slightly decreased thereafter. However, the mid-term and long-term post-SAE CT values were still significantly greater than those on the pre-SAE CT. The SA diameter steadily decreased throughout the follow-up. The SA/CHA decreased until the mid-term. The SA diameter and SA/CHA were significantly smaller upon mid-term and long-term post-SAE CT compared with those at pre-SAE CT. Conclusions The effect of SAE to improve hepatic arterial flow in OLT recipients with SASS might be expected for at least approximately one year. The effect maximally occurred during the short-term after SAE on the basis of changes in the caliber of related arteries upon CT.

Objective To assess whether bioelectrical impedance analysis (BIA) can be used to evaluate the degree of hepatic steatosis in potential living liver donors. Material and Methods From May 2008 to April 2009, BIA was measured in 302 living donor candidates. Correlations among body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), total fatty changes at percutaneous needle liver biopsy, and BIA-derived fat composition were assessed. Results The median (range) BIA-derived fat proportion was 19.4% (4.8%–35.3%), BMI was 24 (17–39), and hepatic steatosis at liver biopsy was 2% (0%–75%). Crude correlations were observed between BIA-derived fat proportion and hepatic steatosis (r2 = 0.14; P = .000), between BMI and hepatic steatosis (r2 = 0.27; P = .000), and between BMI and BIA-derived fat proportion (r2 = .25; P = .000). Receiver operating characteristic curve analysis revealed that the area under the curve of BIA-derived fat proportion was smaller than that of BMI, and no significant cutoff value was identified. Conclusions These results suggest that BIA-derived fat composition alone cannot be used to accurately determine the degree of hepatic steatosis. However, a combination of BMI and BIA-derived fat composition may increase clinical ability to assess hepatic steatosis.

Following implantation into adult recipients, living donor liver grafts usually undergo liver regeneration. This regeneration process may provoke the growth of occult hepatocellular carcinoma (HCC) cells in the recipient body. To assess the risk of HCC recurrence, we analyzed the influence of graft-recipient weight ratio (GRWR).The 181 recipients with HCC within the University of California at San Francisco (UCSF) criteria were divided into four groups according to GRWR: low GRWR (0.8; n = 30), mid GRWR (0.8-1.0; n = 65), high GRWR (1.0; n = 64), and whole liver graft group (1.5; n = 22).There were no differences in overall patient survival (P = .105) and recurrence-free survival (P = .406) among these four groups. GRWR0.8 was not a significant risk factor for HCC recurrence. Similar outcomes were obtained in HCC patients who met the Milan criteria (n = 170).We think that small living donor liver graft and subsequent liver regeneration do not increase the risk of posttransplant HCC recurrence when HCC is within the Milan or UCSF criteria.

In patients with a mediastinal tumor, video-assisted thoracic surgery (VATS) is considered to be associated with more postoperative advantages compared to open procedures. However, open procedures are still preferred in cases with large or malignant tumors. Therefore, in order to determine the appropriate surgical strategies for resection of teratomas, we here review our experience with such cases.Between January 2000 and February 2014, we experienced 132 patients diagnosed with mediastinal teratoma. By using data from a retrospective review of the patients' medical records, we compared the demographic characteristics, hospital stay duration, chest tube indwelling time, operative time, and mass size of the VATS group with those of the patients in the open group. Moreover, we also analyzed the postoperative complications and recurrence. Finally, based on our findings, we created a '∆V (volume of the mass-volume of the cyst in the mass)' capable of determining the appropriate surgical strategy, measured by preoperative computed tomography scan.We excised the mass using VATS in 79 patients, while 53 patients underwent open procedures, including thoracotomy (n = 10) and median sternotomy (n = 43). The operative times, the hospital stay duration, and the chest tube indwelling time were significantly shorter in the VATS group compared to in the open group (Table 1). Four cases were converted to thoracotomy. The mean mass sizes were 6.53 ± 2.20 cm and 8.58 ± 3.45 cm in the VATS and open groups, respectively. The '∆V' of the VATS group was higher than that of the open group. There were three postoperative complications. Table 1 Comparison of the perioperative variables between the VATS group and open groups VATS (n = 79) Open (n = 53) p value Preoperative variables Age (years) 32.34 ± 13.44 29.30 ± 14.76 0.223 Female 63 28 0.001 BMI 22.07 ± 3.34 22.59 ± 3.91 0.409 ASA class 0.272 Class 1 39 21 Class 2 40 32 Mass size (cm) 6.53 ± 2.20 8.58 ± 3.450.001 ∆V (cm(3)) 988.15 ± 1590.85 3093.22 ± 4947.33 0.001 Intraoperative variable Operative time (min) 129 ± 46 170 ± 450.001 Postoperative variable Hospitalization (days) 6.00 ± 3.03 8.94 ± 3.990.001 ICU stay (days) 0 0.42 ± 0.500.001 CTD time (days) 2.00 ± 1.24 3.8 ± 3.630.001 Median F/U duration (months) 47.16 ± 43.60 27.52 ± 34.00 The data are presented as mean ± standard deviation VATS video-assisted thoracic surgery, CTD chest tube indwellingVATS for mediastinal teratoma can be performed safely in selected patients with large or malignant masses. The proposed '∆V' appears to be a useful method for determining the appropriate surgical strategy in the large size teratoma cases.

Background Cardiovascular complications in liver transplant recipients are common. A coronary calcium score >400 determined by coronary computed tomographic angiography (coronary CT) provides useful information for predicting postoperative cardiovascular complications in liver transplant recipients. However, little is known about the association between risk factors and increased coronary calcium scores in coronary CT preformed as a preoperative cardiovascular evaluation before liver transplantation. We evaluated the incidence and cardiovascular risk factors of a coronary calcium score >400 in liver transplant recipients. Methods Between 2013 and 2014, 548 liver transplant recipients were analyzed retrospectively. Preoperative cardiovascular assessments and laboratory data were collected with coronary calcium scores. Univariate and multivariate logistic regression analyses were performed to evaluate cardiovascular risk factors of a coronary calcium score >400 in coronary CT. Results The total mean coronary calcium score was 103 ± 358. Of the 548 recipients, 41 (7.5%) had a coronary calcium score >400. The mean coronary calcium score in patients with a coronary calcium score >400 was 999.7 ± 892.1, and the mean coronary calcium score in patients with a coronary calcium score ≤400 was 30.1 ± 70.9. In multivariate logistic regression analysis, predictors of a coronary calcium score >400 in liver transplant recipients were age (odds ratio [OR] = 1.05, P = .029), male sex (OR = 14.42, P = .009), and diabetes mellitus (OR = 2.04, P = .040). Conclusions We found that old age, male sex, and diabetes mellitus were predictors of a coronary calcium score >400, which is associated with cardiovascular complications after liver transplantation. This study can provide useful information for preoperative cardiovascular evaluation in liver transplant recipients.

Purpose Questions have been raised regarding the ethics of liver transplantation in patients with alcoholic liver disease (ALD), including the fairness of cadaveric organ allocation to individuals who abuse alcohol and the efficacy of transplantation in these patients, many of whom may relapse. Living donor liver transplantation (LDLT) for ALD patients raises the similar ethical issues. ALD candidates for cadaveric liver transplants are required to abstain from alcohol for 6 months before being listed, but the efficacy of 6 months of abstinence in ALD patients receiving LDLT is not known. Methods We therefore determined the efficacy of 6 months of pretransplant abstinence in 15 ALD patients who underwent LDLT from February 1997 to December 2003. Results The Model for End-stage Liver Disease score was 24 ± 10, and mean pretransplant abstinence period was 15 ± 13 months, with 11 (73.3%) patients being abstinent for at least 6 months. Four patients received dual grafts, making the number of living donors 19: 12 children, two wives, one brother, three nephews, and one aunt. There were no unrelated donors. Three patients showed a relapse to alcohol drinking. The overall 1-, 3-, and 5-year survival rates were 100%, 100%, and 87.5%, respectively, and the cumulative 1-, 3-, and 5-year relapse rates were 6.7%, 20%, and 20%, respectively. The relapse rates in patients who did and did not maintain 6 months of abstinence were 9.1% and 50%, respectively; this difference was not significant ( P = .154), likely due to the small sample size. Younger recipient age was a significant risk factor for alcohol relapse (40 ± 8 years versus 53 ± 6 years; P = .004). Conclusions Pretransplant abstinence of 6 months seemed to be beneficial. For ethical reasons, a 6-month abstinence rule should be strictly observed in LDLT.

Purpose The patent covering mycophenolate mofetil (MMF) in Korea has expired and, thus, several generic MMF agents are now commercially available. The supply of Cellcept (Roche Korea) was interrupted at the end of 2011, so it was inevitable that a generic MMF would be used instead. During this period, we performed a prospective pilot study to examine the safety and efficacy of a generic mycophenolate agent (Myconol: Hanmi Pharmaceutical, Seoul Korea) for use as conversion maintenance therapy in stable liver transplantation (OLT) recipients. Methods OLT recipients, who were treated with MMF on an outpatient basis from January 2012 to March 2012, attended follow-up interviews conducted. The patients had undergone OLT ≥ 2 years before the study, had tolerated Cellcept, and showed stable liver function. Fifty-three patients were followed up for more than 3 months after conversion to the same dose of Myconol. Results After conversion to Myconol, 6 patients (11.3%) experienced new side effects, which disappeared when they reverted to Cellcept ( n = 5) or stopped taking Myconol medication ( n = 1). The side effects associated with Myconol included gastrointestinal symptoms (indigestion and diarrhea; n = 3), skin eruptions ( n = 1), pruritus ( n = 1), and insomnia ( n = 1). The mean mycophenolic acid levels were 1.71 ± 0.88 μg/mL for Cellcept and 1.83 ± 0.91 μg/mL for Myconol, which showed a strong correlation ( r 2 = 0.92, P Conclusions Myconol showed similar pharmacokinetics to those of Celcept, but a small proportion of patients experienced agent-specific side effects; therefore, patients should be closely monitored when taking Myconol. Also, further studies, with a greater number of patients, are required to identify the full spectrum of drug-associated side effects.

Purpose Combined hepatocellular carcinoma (HCC) and cholangiocellular carcinoma (CCC) is a rare pair of intrahepatic malignancies. Differential diagnosis among combined HCC-CCC, HCC, or CCC can be difficult; thus malignancies other than ordinary HCC are occasionally encountered unexpectedly in explanted liver specimens. The present study analyzed the long-term outcomes of liver transplantation (OLT) among patients with HCC-CCC. Methods Between January 1999 and December 2009, we performed 2137 adult OLT at our institution including 15 cases of pathologically confirmed HCC-CCC, who all underwent OLT with a pretransplant diagnosis of HCC. We reviewed retrospectively the medical records of these 15 patients. Results Their mean age was 58.9 ± 7.2 years. The median preoperative alpha-fetoprotein level was 32.6 ng/mL. Fourteen patients underwent living donor and one deceased donor OLT. The Milan criteria were met in 12 cases. A single tumor was identified in 8 and multiple lesions in 7 patients. The maximal tumor diameter was 2.9 ± 1.7 cm. Seven patients experienced tumor recurrences: including 6 within the first 12 months. All of the patients who experienced recurrences died at a median 4 months after that diagnosis. The overall patient survival rates were 66.7% at 1 year and 60.0% at 3 and 5 years. Disease-free patient survival rates were 60.0% at 1 year and 53.3% at 3 and 5 years. Conclusions Patients with combined HCC-CCC showed a high rate of early recurrences, particularly within the first year.

The cosmetic aspects of abdominal skin incisions are a matter of concern for both live liver donors and surgeons. We performed a prospective comparative study on the use of minilaparotomy to perform right liver graft harvests with and without hand-assisted laparoscopic surgery (HALS).Young donors were indicated for surgery using minilaparotomy with or without HALS. In the non-HALS group (n = 20), a 10-12-cm-long right subcostal incision was used for right liver graft harvest. In the HALS group (n = 20), an 8-cm-sized right subcostal incision was used for hand assistance and 3 laparoscopic holes made for manipulation. The retrohepatic inferior vena cava (IVC) was initially laparoscopically dissected while using air inflation. The skin incision was extended to 10-12 cm, and then hilar dissection and hepatic transection were performed through the skin incision.In all 40 donors in the study cohort, safe uneventful harvesting of the right liver grafts was successfully achieved through the minilaparotomy incisions. The HALS group required an additional 30 minutes for laparoscopic preparation and dissection compared with the non-HALS group. HALS facilitated retrohepatic IVC dissection, and the remaining part of the surgery was the same as that for minimal-incision surgery. The minimal skin incision for the delivery of the liver from the abdomen was an average 10 cm for grafts 500 g and 12 cm for grafts ≥700 g. Compared with the patient profiles, there were no differences regarding donor age, body mass index, graft weight, intraoperative blood loss, postoperative increase in peak liver enzymes, total hospital stay, and incidence of postoperative complications.HALS facilitates the performance of donor hepatectomy with the use of a minimal incision, which probably allows for a wider selection of living donors.

We report a case of split liver transplantation (SLT) for two adult recipients, which was the first successful case in Korea. The brain-dead donor was a 22-year-old man weighing 65 kg, but his liver volume was estimated as 2120 mL on computed tomographic volumetry. As it seemed to be too large for a 60-kg recipient candidate, SLT was planned after assessment of lobar liver volume and middle hepatic vein anatomy. The right lobe was mobilized first and the liver parenchyma transected along the right border of the middle hepatic vein. The 1240-g right lobe (segments 5 to 8) graft was implanted into a 57-year-old male patient with acute-on-chronic liver failure in the same manner as a living-donor graft. After that, routine procedures of cadaveric multiorgan procurement were performed. The 670-g left lobe (segments 1 to 4) with a retrohepatic vena cava, common bile duct, and aortic patch was implanted into another 37-year-old male recipient. These two recipients recovered uneventfully surviving 12 months to date. We integrated the surgical techniques learned from hundreds of adult-to-adult living donor liver transplants into this first trial of two adult SLT.