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Background The purpose of this study was to identify factors influencing changes in the body mass index (BMI) of kidney transplant (KT) patients and provide data for the management of the BMI of patients who have undergone KT. Method The participants were 106 patients who underwent KT at a single center from August 2014 to June 2017. BMIs were compared and analyzed for 6 months and 24 months after KT, and the survey details were collected through medical records. Analysis was performed between 2 groups, one with increased BMI and the other without. Multivariate logistic regression analysis was performed to identify the factors related to an increase in BMI. Results BMI increased from 22.60 ± 2.72 kg/m2 at 6 months to 23.18 ± 3.06 kg/m2 2 years after KT. The group with increased BMI (n = 39) had more patients with higher low-density cholesterol levels at the time of KT (low-density cholesterol ≥100 mg/dL; 34 [54.0%] vs 10 [26.3]; P = .008) and without statin drug use than the other group (n = 67) (statin drug use, 48 [70.6%] vs 34 [87.2%], P = .044). Multiple logistic regression analysis showed that age >50 years (odds ratio [OR] = 2.942; 95% confidence interval [CI], 1.075-8.055; P = .036), low-density lipoprotein >100 mg/dL at KT (OR = 6.618; 95% CI, 2.225-19.682; P = 0.001), and no statin drugs (OR = 5.094; 95% CI, 1.449-17.911, P = .011) were the risk factors for an increased BMI after KT. Conclusions After KT, to prevent an increase in the BMI, clinicians should strongly recommend the use of drugs to treat hyperlipidemia, especially in elderly patients with high low-density lipoprotein levels before KT.

BACKGROUND The survival outcomes of recurrent hepatocellular carcinoma (HCC) after curative resection remain unclear due to lack of clear basis for the selection of treatment option. We investigated overall survival (OS) after intrahepatic recurrence and re-recurrence free survival (rRFS) of the patients with recurrent HCC, and whether Milan criteria (MC) status at resection and recurrence impacts on OS and rRFS. METHOD We enrolled 959 patients who experienced recurrence after primary hepatic resection for HCC. We divided the cohort into four groups according to MC at two periods: IN-rIN MC (HCC within MC at the time of resection-recurrence within MC), IN-rOUT MC (HCC within MC at the time of resection-recurrence outside MC), OUT-rIN MC (HCC outside MC at the time of resection-recurrence within MC), and OUT-rOUT MC (HCC outside MC at the time of resection-recurrence outside MC). RESULTS In the entire cohort, 1-, 3-, and 5-year OS after recurrence was 81.0%, 55.7%, and 45.8%, respectively, while rRFS was 63.7%, 46.1%, and 42.0%, respectively. The IN-rIN MC group had the best outcomes (5-year OS and rRFS, 54.5% and 45.7%, respectively). The IN-rOUT and OUT-rIN MC groups had better 5-year OS outcomes than the OUT-rOUT MC group (46.5%, 38.6%, and 24.8%, respectively; P 0.05). CONCLUSION Survival after first recurrence following curative primary resection for HCC was affected by MC at both time of resection and recurrence. Both the IN-rOUT and OUT-rIN MC groups with similar survival outcomes can be saved via curative treatment.

The pure laparoscopic approach to donor hepatectomy is being taken more often. However, few centers perform pure laparoscopic donor right hepatectomy (PLDRH) because it requires a high level of surgical skill. Studies reporting initial outcomes of PLDRH may prompt further implementation of the technique and help reduce initial learning curves at other transplant centers. This study reports performance of PLDRH at a single center with extensive experience of adult living donor liver transplantation.Data from 115 donors (and recipients) who underwent PLDRH between November 2015 and June 2017 were analyzed retrospectively. Subgroup analysis was performed to compare outcomes between the initial (November 2015 to October 2016) and more recent (November 2016 to June 2017) periods.During the initial period, 3 (2.6%) donors experienced complications greater than grade III on the Clavien-Dindo scale. By contrast, no donors developed complications during the recent period. The operative time (293.6 minutes vs 344.4 minutes; P0.001) and hospital stay (7.3 days vs 8.3 days; P = 0.002) were significantly shorter during the more recent period. Also, Δhemoglobin (Hb)%, calculated as ΔHb% = [(preoperative Hb - postoperative Hb)/preoperative Hb] × 100 (14.9% vs 17.5%; P = 0.042), and Δaspartate aminotransferase (AST)%, calculated as ΔAST% = [(peak AST - preoperative AST)/preoperative AST] × 100 (1048.9% vs 1316.6%; P = 0.009), were significantly lower during the recent period.Pure laparoscopic donor right hepatectomy is both feasible and safe when performed at a center experienced in adult living donor liver transplantation. Performance of about 60 PLDRHs over 1 year is sufficient to standardize the procedure.

There are three pathophysiologies of involutional entropion, vertical laxity (VL), horizontal laxity (HL), and overriding of the preseptal orbicularis. The effects of methods to correct VL only, HL only, or both VL and HL in patients with involutional entropion were compared using the published results of randomized controlled trials (RCTs).To find RCT studies that investigated methods to correct involutional entropion, a systematic search was performed from database inception to April 2020 in the Medline, EMBASE, and Cochrane databases. Two independent researchers conducted the literature selection and data extraction. Evaluation of the quality of the reports was performed using the Cochrane Collaboration tool for assessing the risk of bias (ROB 2.0). The data analysis was conducted according to the PRISMA guidelines using Review Manager 5.3.Two RCT studies were included in this meta-analysis. Surgery for involutional entropion was performed on a total of 109 eyes. Everting sutures (ES) were used on 57 eyes and lateral tarsal strips (LTS) or combined procedures (LTS + ES) were performed on 52 eyes. At the end of the follow-up periods, involutional entropion recurred in 18 eyes (31.6%) in the ES group and three eyes (5.8%) in the LTS +/- ES group. Analysis of the risk ratio showed that the LTS +/- ES method significantly lowered the recurrence rate compared to using ES only (P = 0.007).Performing LTS +/- ES effectively lowered the recurrence rate of involutional entropion compared to ES alone. However, some patients cannot tolerate more invasive corrections such as LTS. Therefore, sequential procedures, in which ES is performed first and then when entropion recurs LTS +/- ES is performed, or another methods depending upon the degree of HL may be used.

All over the world there is serious concern about the shortage of organs available for transplantation. In an effort to address this, transplantation with grafts, which was previously considered a contraindication, are now performed. In some cases, this practice has contributed to increasing the organ pool. Fibromuscular dysplasia (FMD) is the second-most-common cause of renovascular hypertension and is observed in 2%-6.6% of potential live kidney donors. Kidney with FMD is generally considered to be a contraindication for renal transplantation because renal artery stenosis may progress after transplantation and cause graft loss. Here, we report on a successful case of kidney transplantation using a graft with FMD of a deceased donor who had multiple aneurysms in the renal artery.

Aim To investigate the rates of pretransplantation fetal-maternal microchimerism (MC) and its effect on rejection in children receiving maternal liver grafts. Methods DNA or blood samples before liver transplantation (LT) were available in 45 pediatric patients and their mothers. The presence of pretransplantation MC to non-inherited maternal antigens (NIMAs) (NIMA-MC) in the peripheral blood was tested using nested PCR-single-strand conformation polymorphism analysis for the human leukocyte antigen (HLA)-DRB1 alleles. NIMA-MC was successfully evaluated in 26 of the 45 children. Among these 45 pediatric LT recipients, 23 children (51.1%) received transplants from maternal donors and the other 22 from non-maternal donors. Results Among these 26 children, pretransplantation NIMA-MC was detected in 23.1% (n = 6), 6.1 (range, 0.8-14) years after birth. Among the children with a maternal donor, the rate of biopsy-proven cellular rejection (BPCR) was 0% in patients with NIMA-MC positivity (0/3) and those with HLA-DR identity with the mother (0/4), but it was 50% in those with NIMA-MC negativity (5/10). Patients with NIMA-MC positivity or HLA-DR identity with the mother showed significantly lower BPCR rate compared with NIMA-MC-negative patients (0% vs 50%, P = 0.04). NIMA-MC-positive patients tended to show lower BPCR rate compared with NIMA-MC-negative patients (P = 0.23). Conclusion The presence of pretransplantation NIMA-MC or HLA-DR identity with the mother could be associated with BPCR-free survival in pediatric recipients of LT from maternal donors.

The indication of liver transplantation (LT) for the treatment of advanced hepatocellular carcinoma (HCC) is expanding. However, portal vein tumor thrombus (PVTT) has been still accepted as an absolute contraindication. We experienced an unexpectedly good prognosis in selected patients. Therefore, we tried to identify the prognostic factors after LT for HCC with major PVTT. Among 282 patients who underwent living donor liver transplantation (LDLT) for HCC from January 2009 to December 2013, 11 (3.9%) patients with major PVTT that was preoperatively diagnosed were investigated. The 1-, 3-, and 5-year recurrence-free survival rates were 63.6%, 45.5%, and 45.5%, respectively, and all recurrent cases showed intrahepatic and extrahepatic recurrence. The 1-, 3-, and 5-year overall survival rates were 72.7%, 63.6%, and 63.6%, respectively, and 2 patients with delayed recurrence survived approximately 5 years after LT. Main portal vein (PV) invasion (P

Liver transplantation is an effective treatment modality for hepatocellular carcinoma (HCC). Due to deceased organ shortage, living donor liver transplantation (LDLT) accounts for the majority of liver transplants in Korea. The aim of this study is to evaluate the recent trend of LDLT for HCC, and to suggest guidelines and criteria for selecting the appropriate candidates for LDLT.Between January 2000 and December 2015, 532 patients underwent LDLT for HCC. Clinicopathologic data were analyzed as well as overall survival rate (SR) and disease-free survival rate (DFSR) according to the Milan criteria based on explant pathology, positron emission tomography (PET) positivity, and serum alpha-fetoprotein (AFP) level.The 5-year overall SR and DFSR were 81.5% and 75.5% respectively. According to our previously reported combination of AFP and PET [Seoul National University Hospital (SNUH) criteria]; low risk group [AFP200 ng/mL, PET (-)], intermediate risk group [AFP200 ng/mL, PET (-) or AFP200 ng/mL, PET (+)], and high risk group [AFP200 ng/mL, PET (+)], the 5-year DFSR of low risk group was 86.1%, intermediate risk group was 79.0%, and high risk group was 18.5% (P0.001). Within the Milan criteria, the 5-year DFSR of low risk group was 88.4%, intermediate risk group was 79.9%, and high risk group was 60.0% (P=0.016). Beyond the Milan criteria, the 5-year DFSR of low, intermediate, and high risk group was 80.3%, 77.7%, and 9.1%, respectively (P0.001).In conclusion, our data and experience suggest that a continued paradigm shift from a conventional size based criteria to a biological marker based criteria is indicated when evaluating LDLT candidates with HCC.

Background Some patients with hepatocellular carcinoma (HCC) recurrence after LT show good long-term survival. We aimed to determine the prognostic factors affecting survival after recurrence and to suggest treatment strategies. Methods Between January 2000 and December 2015, 532 patients underwent adult living donor liver transplantation (LDLT) for HCC. Among these, 92 (17.3%) who experienced recurrence were retrospectively reviewed. Results The 1-, 3-, and 5-year survival rates after recurrence were 59.5%, 23.0%, and 11.9%, respectively. In multivariate analysis, time to recurrence >6 months and surgical resection after recurrence were related to longer survival after recurrence, while multi-organ involvement at the time of primary recurrence was related to poorer survival. We classified patients into early (≤6 months) and late (>6 months) recurrence groups. In the early recurrence group, tumor size >5 cm in the explant liver, liver as the first detected site of recurrence, and multiple organ involvement at primary recurrence were related to survival on multivariate analysis. In the late recurrence group, mammalian target of rapamycin inhibitor (mTORi) usage and multi-organ involvement were significantly associated with the prognosis on multivariate analysis. Conclusions Various therapeutic approaches are needed depending on the period of recurrence after LT and multiplicity of involved organs.

Purpose The aim of this study was to determine the survival benefit based on different treatment strategies in patients with small, solitary, recurring intrahepatic hepatocellular carcinomas (HCCs) that were defined as recurred Barcelona Clinic Liver Cancer stage O (reBCLC-O). Methods Among the 917 patients with HCC recurrence after primary hepatic resection, 394 patients with reBCLC-O were selected. Of these, 150 patients underwent curative treatment (re-resection, radiofrequency ablation, and liver transplantation) and 203 underwent transarterial chemoembolization (TACE) group for recurrent HCC. After propensity score matching (PSM), both the groups were well balanced (89 patients in each group). Results Before PSM, the 1-, 3-, and 5-year overall survival (OS) rates of patients in the curative treatment group (96.7%, 78.6%, and 70.5%, respectively) were significantly better than those in the TACE treatment group (95.6%, 53.7%, and 44.2%, respectively) (P < 0.001). After PSM, the 1-, 3-, and 5-year OS rates also differed significantly (92.0%, 79.6%, and 71.1% in the curative treatment group vs. 88.8%, 65.6%, and 57.9% in the TACE group) (P = 0.005). The independent predictors of worse OS were tumor number at the time of resection and treatment modality for the recurrence, time interval to recurrence, and prothrombin time international normalized ratio and alpha-fetoprotein levels at the time of recurrence. Conclusion The OS of patients in the curative treatment group was better than that in the non-curative treatment group after PSM. Based on our results, curative treatment should be strongly recommended in the patients with reBCLC-O recurrence for better survival.

Purpose To investigate the change in urinary urgency and predictors of urgency improvement after holmium laser enucleation of the prostate (HoLEP) in men with benign prostatic hyperplasia (BPH). Materials and methods We retrospectively analyzed the medical records of patients who were treated with HoLEP for BPH and had preoperative urgency measuring ≥3 on a 5-point urinary sensation scale. Those with prostate cancer diagnosed prior to or after HoLEP, a history of other prostatic and/or urethral surgery, moderate to severe postoperative complications, and neurogenic causes were excluded. Patients who had improved urgency with antimuscarinic medication after HoLEP were excluded. We divided the patients into 2 groups based on urgency symptoms 3 months after HoLEP: improved and unimproved urgency. Improved urgency was defined as a reduction of 2 or more points on the 5-point urinary sensation scale. Preoperative clinical and urodynamic factors as well as perioperative factors were compared between groups. Results In total, 139 patients were included in this study. Voiding parameters in all patients improved significantly after HoLEP. Seventy-one patients (51.1%) had improved urgency, while 68 (48.9%) did not show any improvement. A history of acute urinary retention (AUR) and postvoid residual were associated with postoperative urgency improvement in univariate analysis. In multivariate analysis, a history of AUR was an independent factor affecting urgency improvement. Conclusions A preoperative history of AUR could influence the change in urgency after HoLEP surgery in patients with BPH.

Alveolar hemorrhage is a life-threatening clinical syndrome often initially thought to be atypical pneumonia. Association with hematopoietic stem cell transplantation is well studied, but not with solid organ transplantation. We report a case of a 54-year-old woman presented with fever and shortness of breath on the third posttransplant day after deceased donor liver transplantation. Imaging studies showed diffuse bilateral pulmonary infiltrates and a positive sequential bronchoalveolar lavage test was revealed during bronchoscopy. Cytomegalovirus antigenemia was present in 8/200,000 white blood cells; Aspergillus galactomannan and Pneumocystis jirovecii were also present. However, only Aspergillus hyphae were found in the sputum culture. Management strategy aimed to treat underlying infections, provide adequate respiratory support, and control inflammation. We proposed that diffuse alveolar hemorrhage should be considered as differential diagnosis in early pulmonary complications after liver transplantation. Early diagnosis and aggressive treatment protocol is the key for a good outcome.

Background Hepatitis B core antibody-positive (HBcAb+) graft is known as a risk for de novo hepatitis B virus (HBV) infection in recipients after liver transplantation (LT). However, little is known about the possibility or incidence of de novo HBV infections after LT in hepatitis B surface antigen-negative (HBsAg−)/HBcAb+ recipients using HBsAg−/HBcAb− grafts. The study aimed to evaluate the prevalence of de novo HBV infection in HBsAg−/HBcAb+ recipients using HBsAg−/HBcAb− grafts. A retrospective review was performed with the records of 1129 adult patients who underwent primary LT at a single institution in an HBV endemic area between January 2000 and December 2013. A total of 78 patients (6.9%) were reviewed for de novo HBV infection after LT. De novo HBV infection was developed in 1 patient (1.28%). The patient was a 65-year-old woman who underwent LT due to alcoholic liver cirrhosis. De novo HBV was not related to graft loss or death and well treated with tenofovir. In conclusion, de novo HBV infections may occur in HBsAg-/HBcAb+ recipients using HBsAg−/HBcAb− grafts, and caution is needed in these patients.

Liver transplantation (LT) is an excellent treatment option for patients with biliary atresia (BA) who fail portoenterostomy surgery. LT is also increasingly performed in patients with metabolic liver diseases. This study compared the outcomes in pediatric patients who underwent LT for metabolic liver diseases and BA.Data from 237 pediatric patients who underwent primary LT at Seoul National University Hospital from 1988 to 2015, including 33 with metabolic liver diseases and 135 with BA, were retrospectively analyzed.Compared with children with BA, children with metabolic liver diseases were significantly older at the time of LT (121.3 vs. 37.3 months; P 0.001), and had lower Child-Pugh (7.1 vs. 8.4; P = 0.010) and Pediatric End-stage Liver Disease (6.5 vs. 12.8; P = 0.042) scores. Overall survival rates were similar (87.8% vs. 90.8%; P = 0.402), but hepatic artery (HA) complications were significantly more frequent in children with metabolic liver diseases (12.1% vs. 1.5%; P = 0.014).Despite similar overall survival, children with metabolic liver diseases had a higher rate of HA complications.Original article, Case control study, Retrospective.III.

Improvements in laparoscopic imaging systems and instruments have increased the performance of pure laparoscopic living donor hepatectomy. This operation is no longer limited to left lateral sectionectomy but is used for left hepatectomy and right hepatectomy.1-5 This report describes a donor who underwent pure laparoscopic left lateral sectionectomy and in situ reduction using 3D laparoscopy and indocyanine green (ICG) near-infrared fluorescence cholangiography to obtain a monosegment. A 43-year-old woman offered to donate part of her liver to her daughter, who required a transplant for acute liver failure after a Kasai operation for biliary cirrhosis caused by biliary atresia. Donor height was 150.4 cm, body weight was 56.8 kg, and body mass index was 25.1 kg/m2. Liver dynamic CT showed a left lateral liver volume of 223 cm3, and an estimated graft-to-recipient weight ratio (GRWR) of 4.4%. The entire procedure including in situ reduction was performed under 3D laparoscopic view. The optimal bile duct division point was determined by real time ICG fluorescence cholangiography. The total operation time was 320 min, with no transfusion required and no intraoperative complications. Intraoperative real time ICG fluorescence cholangiography revealed the donor’s bile duct anatomy and identified the optimal division point. The final graft weighed 167 g, 48 g being reduced in situ, with a GRWR of 3.3%. The donor was discharged on postoperative day 8 with no complications. Pure 3D laparoscopic left lateral sectionectomy and in situ reduction are feasible for obtaining a donor monosegment for pediatric living donor liver transplantation.

Purpose: To investigate the role of α3 and α7 nicotinic acetylcholine receptor subunits (nAChRs) in the bladder, using a rat model with detrusor overactivity induced by partial bladder outlet obstruction (BOO). Methods: Forty Sprague-Dawley rats were used: 10 were sham-operated (control group) and 30 were observed for 3 weeks after partial BOO. BOO-induced rats were further divided into 3 groups: Two groups of 10 rats each received intravesicular infusions with hexamethonium (HM group; n=10) or methyllycaconitine (MLC group; n=10), which are antagonists for α3 and α7 nAChRs, respectively. The remaining BOO-induced rats received only saline infusion (BOO group; n=10). Based on the contraction interval measurements using cystometrogram, the contraction pressure and nonvoiding bladder contractions were compared between the control and the three BOO-induced groups. Immunofluorescent staining and Western blotting were used to analyze α3 and α7 nAChRs levels. Results: The contraction interval of the MLC group was higher than that of the BOO group (P

To evaluate the potential of anthocyanin as a supplement for the treatment of Peyronie disease (PD) by examining the anti-inflammatory and antifibrosis activities of anthocyanin in a PD animal model.We performed the preliminary experiment to confirm the plaque formation of tunica albuginea (TA). Six animals received fibrin (TISSEEL VH Sealer; Baxter, Glendale, CA; 30 μL each of human fibrin and thrombin solutions) injections into the TA. After 2 weeks, PD-like plaque formation was confirmed by Masson trichrome staining in preliminary experimental animal group. A PD rat model was made by intratunical injection of fibrin. Experimental animals were divided into 3 groups as follows: control group (n = 8), PD group (n = 8), and anthocyanin-treated group (n = 8) that received anthocyanin at 50 mg/kg twice a day for 4 weeks using orogastric tubes. After 4 weeks, penile tissue was collected to perform Masson trichrome and transforming growth factor (TGF)-β1 staining.We confirmed PD-like plaque formation by Masson trichrome stain 2 weeks after fibrin injection. The ratio of smooth muscle cells in the corpus cavernosum in the PD group was significantly lower than that of the control group (P.05). The PD group showed strong TGF-β1 immunoreactivity with increased expression in the collagenous connective tissues and fibroblasts around the TA.We confirmed PD-like plaque formation after 2 weeks of fibrin injections into the TA. This is the first study to suggest that anthocyanin extracted from black soybean may have anti-inflammatory and antifibrotic effects for penile plaque formation in rat PD models.

Patients with large spontaneous splenorenal shunts (SRSs) prove challenging during liver transplantation (LT), regardless of organizing portal vein (PV) thrombosis. Here, we detail the clinical outcomes of 26 patients who underwent direct ligation of large SRSs during LT. Direct ligation of large SRS was applied in poor portal flow during LT. We performed temporary test clamping of the SRS before direct ligation and applied PV pressure monitoring in patients who showed signs of portal hypertension, such as bowel edema. We retrospectively reviewed and evaluated their clinical outcomes. Among 843 patients who underwent LT between 2010 and 2015, 26 (3.1%) underwent direct ligation of SRS without any intraoperative event. Mean preoperative Model for End-Stage Liver Disease score was 16.7 ± 9.0. The main PV diameter on preoperative computed tomography was 8.3 ± 3.4 mm (range, 3.0-14.0 mm). SRS was easily identified at just below the distal pancreas and beside the inferior mesenteric vein in all patients. Accompanying PV thrombectomy was done in 42.3% of patients. Among 26 patients, massive and prolonged ascites was evident in 15.4% (n = 4) postoperatively. They were all living donor LT recipients with a small PV diameter (4.0-6.7 mm). Except for 1 patient who underwent splenic artery embolization, ascites was tolerable and well controlled by conservative management. There was a 7.7% rate of major complications related to direct ligation, including reoperation due to combined ligation of SRS along with a left renal vein at the confluence. Except for 1 hospital mortality due to sepsis, 25 patients (96.2%) are alive with no evidence of further PV complications. In conclusion, direct ligation of large SRS during LT is a safe and feasible method to overcome the effects of a large SRS. Liver Transplantation 23 899-906 2017 AASLD.

Purpose: Since the introduction of short vein bypass (SVB), many have reported its feasibility when long vein bypass (LVB) cannot be performed due to limited vein conduit. However, the presence of inflow-vessel disease may affect graft patency and thus require endovascular treatment prior to surgery. Our study aims to analyze the results between SVB and LVB. Materials and Methods: From 2009 to 2013, 27 bypass procedures were reviewed retrospectively. Outcomes such as patency rate, postoperative ankle brachial index (ABI) and limb salvage rate between SVB and LVB were compared. Wound healing time and primary patency rate were analyzed and the former was also analyzed according to the respective angiosome and revascularization type. Results: There were 11 males and 16 females and the mean age was 66.6±12.3 years. Twenty four patients had TransAtlantic Inter-Society Consensus (TASC) D and 3 patients had TASC C lesions below knee. The 1-year cumulative patency rate between SVB and LVB were 63% and 66%, P=0.627. The limb salvage rate (100% vs. 73%; P=0.280) and postoperative ABI (0.592 vs. 0.508; P=0.620) were higher in the SVB group than in the LVB group, although the differences were not significant. There was no difference in wound healing time by angiosomal revascularization type. In situ vein graft showed higher patency rate than reversed greater saphenous vein (75% vs. 61%; P=0.00) Conclusion: The results of SVB were similar to those of LVB. SVB is feasible in the setting of limited conduit availability, in combination with endovascular treatment in the presence of proximal lesions.

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. Several recent findings that there are activating mutations in the KIT and PDGFRA (platelet-derived growth factor receptor-α) genes of GISTs provide the rationale for using targeted therapies such as imatinib or sunitinib. Sunitinib, an oral multitargeted receptor tyrosine kinase inhibitor that inhibits kinases such as KIT, PDGFR (platelet-derived growth factor recepter), and VEGFR (vascular endothelial growth factor receptor), was recently approved for the treatment of imatinib-refractory GIST. Sunitinib is generally well tolerated and has an acceptable toxicity profile; an adverse event such as bowel perforation is rare. We present a patient with imatinib-refractory GIST who was successfully treated using sunitinib, but developed bowel perforation. The mechanism involved in bowel perforation associated with sunitinib is unknown. However, we presume that in our patient, the dramatic reduction in disseminated peritoneal metastases and bowel invasion of recurrent GIST during sunitinib treatment might have resulted in the bowel perforation.

Background The need for liver retransplantation (re-LT) has been increasing. Here we describe the outcome and technical aspects of re-LT during 25 years in a single major center. Methods We retrospectively reviewed patients who underwent LT from March 1988 to February 2013. Among 1,312 LTs during 25 years, 38 (2.9%) were re-LTs, including 28 adults (mean age 52.0 y) and 10 children (mean age 5.7 y). Results The most common indication was primary nonfunction in early re-LT and biliary complication in late re-LT. Preoperative major comorbidity was very common (81.6%). Among them, infection was the most frequent (52.6%). Living-donor re-LT constituted 21.1%. In operative technique, nonconventional methods were substantially performed, including high hilar dissection for hepatectomy (>50%), arterial anastomosis with the use of right gastroepiploic or jump graft (23.7%), and hepaticoenterostomy (60.5%). Several reanastomoses were needed in 10.5% for artery and 5.3% for duct. In adults and children, mean estimated blood losses were 9,541 mL and 977 mL, respectively. Mean operative times for adults and children were 508 and 432 minutes, respectively. In-hospital mortality was 35.7% in adults and 40.0% in children. The main cause of death was sepsis for both adults and children. Survival rates at 1 month and 1, 3, and 5 years were, respectively, 89.4%, 56.5%, 50.3%, and 50.3% in adults, and 70.0%, 60.0%, 60.0%, and 60.0% in children. Conclusions Outcome of re-LT is poorer than primary LT regardless of the cause of graft failure. Therefore, more technical concerns need to be considered. We also need more efforts to control perioperative infections to improve survival after re-LT.

Purpose: The aim of this study was to investigate the preoperative factors related to early quality of life (QoL) in patients with benign prostatic hyperplasia after holmium laser enucleation of the prostate (HoLEP) during the surgeon’s learning curve. Methods: The medical records of 82 patients with a follow-up period of at least 3 months who were treated with HoLEP during the time of a surgeon’s learning curve were analyzed retrospectively. We divided the patients into two groups on the basis of the QoL component of the International Prostate Symptom Score (IPSS) 3 months after HoLEP: the high QoL group (IPSS/QoL≤3) and the low QoL group (IPSS/QoL≥4). Preoperative factors in each group were compared, including prostate volume, prostate-specific antigen, history of acute urinary retention (AUR), urgency incontinence, IPSS, and urodynamic parameters. Detrusor underactivity was defined as a bladder contractility index less than 100 on urodynamic study. Results: A total of 61 patients (74.3%) had a high QoL, whereas 21 (25.7%) had a low QoL. A history of AUR, detrusor pressure on maximal flow (PdetQmax), bladder outlet obstruction grade, bladder contractility index, and detrusor underactivity were associated with postoperative QoL in the univariate analysis. In the multivariate analysis, a history of AUR and PdetQmax were independent factors affecting postoperative QoL. Conclusions: A history of AUR and bladder contractility affect early QoL, and preoperative urodynamic study plays an important role in the proper selection of patients during the HoLEP learning curve.

The process of evaluating potential donors in liver transplantation is important to ensure donor safety and provide optimal recipient outcomes. However, there has been no report about donor exclusion rates and reasons for such exclusion in Korea. In this study, we aimed to elucidate the outcomes of potential living liver donor evaluation in a major living donor liver transplantation center. From July 2011 to June 2015, prospectively collected data of 726 potential donors for 588 matched recipients were subsequently evaluated. Among 726 potential donors, 374 potential donors (51.5%) finally reached donation; 352 potential donors (48.5%) were excluded for various reasons. Donor reasons were 29.8%, including medical problems, withdrawal of consent, graft volume issues, and identification of a better suitable donor. Recipient reasons were 20.7%, including recipient death or recovery, allocation to deceased donor, and progressions of hepatocellular carcinoma. A total of 38 (5.2%) potential donors had a fatty liver. Among them, 15 (39.5%) potential donors tried short-term weight reduction and eventually were able to donate. In conclusion, the main reasons for donor exclusion were medical problems and withdrawal of consent. Therefore, thorough medical screening and careful examination for donor voluntarism are important in the donor evaluation process. Liver Transplantation 23 614-624 2017 AASLD.

The aim of this study is to investigate changes in urinary nerve growth factor (NGF) and prostaglandin E(2) (PGE(2)) in women with overactive bladder (OAB) following anticholinergic treatment.A total of 30 female patients with OAB were enrolled and the control group included 15 healthy women who did not present any bladder symptoms. All subjects with OAB recorded voiding diaries, underwent urodynamic study, and were evaluated for urgency grade. They received anticholinergic treatment for 4 weeks, after which they were again evaluated for urinary urgency grade and voiding diaries. OAB patients were classified into three groups according to the change on the 5-point Urinary Sensation Scale after the treatment: group 1 (no change in urgency grade), group 2 (1 point of improvement), and, group 3 (more than 2 points of improvement). Urinary NGF and PGE(2) levels between controls and OAB patients (before and after treatment in groups 1, 2, and 3) were compared.Urinary NGF and PGE(2) levels were significantly higher in OAB patients than in the controls. NGF levels were not significantly different between pre- and post-treatment in groups 1 and 2. However, in group 3, NGF levels were significantly decreased after treatment. PGE(2) levels were not significantly different between pre- and post-treatment in either group.NGF and PGE(2) have important roles in the development of OAB symptoms in women. Initial reduction of urgency severity after anticholinergic treatment in women with OAB could be associated with decreasing urinary NGF levels.

Despite increases in the performance of pure laparoscopic living donor hepatectomy, variations in the bile duct or portal vein have been regarded as relative contraindications to this technique [1-3]. This report describes a donor with separate right posterior and right anterior hepatic ducts and portal veins who underwent pure laparoscopic living donor right hemihepatectomy, integrated with 3D laparoscopy and indocyanine green (ICG) near-infrared fluorescence cholangiography [1, 4, 5].A 50-year-old man offered to donate part of his liver to his older brother, who required a transplant for hepatitis B-associated liver cirrhosis and hepatocellular carcinoma. Donor height was 178.0 cm, body weight was 82.7 kg, and body mass index was 26.1 kg/mThe total operation time was 443 min; the donor required no transfusions and experienced no intraoperative complications. The graft weighed 1146 g with a graft-to-recipient weight ratio of 1.88%. The optimal bile duct division point was identified using ICG fluorescence cholangiography, and the bile duct was divided with good patency without any stricture. The right anterior and posterior portal veins were transected with endostaplers without any torsion. The patient was discharged on postoperative day 8, with no complications.Using a 3D view and ICG fluorescence cholangiography, pure 3D laparoscopic living donor right hemihepatectomy is feasible in a donor with separate right posterior and right anterior hepatic ducts and portal veins.

Purpose: Transrectal ultrasound-guided prostate biopsy is the procedure of choice for diagnosing prostate cancer. We compared with pain-relieving effect of acetaminophen, a known drug for enhancing the pain-relieving effect of tramadol, and eutectic mixture of local anesthetics (EMLA), a local anesthetic agent, with that of the conventional periprostatic nerve block method. Materials and Methods: This was a prospective, randomized, single-blinded study. A total of 430 patients were randomly assigned to three groups. Group 1 received a periprostatic nerve block with 1% lidocaine, group 2 received acetaminophen 650 mg, and group 3 received EMLA cream for pain control. All patients were given 50 mg of tramadol intravenously 30 minutes before the procedure. At 3 hours after completion of the procedure, the patients were asked to grade their pain on a horizontal visual analogue scale (VAS). The patients were also asked whether they were willing to undergo future biopsy if required. Results: There were no significant differences between the three groups in terms of age, prostate-specific antigen, prostate size, or numbers of biopsy cores. The pain scores for groups 2 and group 3, which were 3.47±1.92 and 3.50±1.36, respectively, were similar and were significantly lower than that of group 1, which was 5.24±2.07. Conclusions: Acetaminophen and EMLA cream with intravenous injection of tramadol are safe, easy, and effective methods of controlling pain during the procedure. These methods were more effective for pain relief than was the conventional periprostatic nerve block method.

To determine the effects of alpha-blocker, extracorporeal magnetic innervations (ExMI) alone and combination treatment on female bladder outlet obstruction (BOO).Sixty women with BOO were divided into three groups according to the treatment. After 3 months, the clinical outcomes were evaluated by clinical examination, international prostatic symptom score (IPSS), quality of life (QOL), 3-day voiding diary, uroflowmetry and post-void residual.At 3 months, symptom improvement was 52.6% in alpha-blocker monotherapy (group I), 50.0% in ExMI monotherapy (group II), and 57.1% in combination therapy (group III). Maximum flow rate increased and total IPSS decreased significantly in all groups (p0.05). Storage symptom subscore was more reduced in groups II and III and QOL improved significantly in group III (p0.05)This study demonstrates that both alpha-blocker and ExMI were effective in female BOO, and ExMI may be more effective for improving storage symptoms.

RATIONALE Hepatectomy in a patient with situs inversus totalis (SIT) is technically challenging, and pure laparoscopic major hepatectomy has not been previously described. PATIENT CONCERNS A 70-year-old male with SIT was referred to our hospital for investigation and treatment of a liver mass in segment 5/6. DIAGNOSIS Computed tomography (CT) and magnetic resonance imaging (MRI) showed features of chronic liver disease and a 5-cm sized mass with a bulging contour at segment 5/6. INTERVENTIONS Pure laparoscopic right hepatectomy was performed. OUTCOMES There was no intraoperative complication and the procedure was completed without a transfusion. The patient recovered well and was discharged on postoperative day 8. LESSONS Considering the position of the port sites and the assistant, and the operator's hand for the working port, a pure laparoscopic right hepatectomy can be a feasible procedure, even in a patient with SIT.

Extragonadal teratoma originating from the retroperitoneum represents less than 5% of all teratomas and accounts for less than 10% of all pediatric retroperitoneal neoplasms. To date, there has been no report of teratoma managed with LT. This study reports an infant aged 3 months with retroperitoneal immature teratoma involving the hepatic hilum, refractory to chemotherapy and treated with LT. The patient was referred to our hospital for management of a growing abdominal mass. Histopathology of a fine needle biopsy of the lesion suggested the possibility of a hepatoblastoma with teratoid features. Cisplatin-based chemotherapy was initiated, but rapid growth of the tumor encasing the hepatic artery proper was detected, even after two cycles of chemotherapy. A split LT was carried out, and pathological examination of the explanted liver revealed the involvement of numerous neuroepithelial components, confirming the diagnosis of a Norris grade 3 immature teratoma. The patient recovered well and was discharged on day 19 post-LT. As on date, on postoperative day 240, he has completed seven cycles of a 12-cycle vinblastine and doxorubicin-based adjuvant chemotherapy.

We estimated the effect of various immunosuppressants (ISs) and metformin (M) to provide theoretical background of optimal therapeutic strategy for de novo colon cancer after liver transplantation (LT). Three colon cancer cell lines (HT29, SW620, and HCT116) were used in in vitro studies. HT29 was also used in BALB/c-nude mice animal models. Following groups were used in both in vitro and in vivo studies: sirolimus (S), tacrolimus (T), cyclosporin A (CsA), M, metformin/sirolimus (Met/S), metformin/tacrolimus (Met/T), and metformin/cyclosporin A (Met/CsA). 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay was performed and western blot analyses were performed for mTOR pathway proteins, apoptosis proteins, and epithelial-mesenchymal-transition (EMT) proteins. Tumor volume was measured for 4 weeks after inoculation. MTT-assay revealed significant cell viability inhibition in all 3 colon cancer cell lines in groups of S, M, and Met/S. Of note, group Met/S showed synergistic effect compare to M or S group. Western blot analysis showed significant low levels of all investigated proteins in groups of S and Met/S in both in vitro and in vivo experiment. Tumor growth was significantly inhibited only in the Met/S group. Combination of Met and S showed the most potent inhibition in all colon cancer cell lines. This finding might have application for de novo colon cancer., Graphical Abstract

To investigate the effects of new herbal formula (KBMSI-2) on erectile dysfunction in streptozotocin (STZ)-induced diabetic rat model.Twenty four Sprague-Dawley male rats were randomly divided into three groups; control (n=8), diabetes model (n=8), diabetes + KBMSI-2 200 mg/kg treatment (n=8) groups. The diabetes induced groups received a single intraperitoneal injection of STZ. Distilled water was administered in the control and model groups. To investigate the penile erection, intracavernosal pressure (ICP) and intracavernosal pressure/mean arterial pressure (ICP/MAP) were recorded in all groups. Serial sections of the penis were used to perform Masson's trichrome stain. The expression of neuronal nitric oxide synthase (nNOS), endothelial NOS (eNOS) and cyclic guanosine monophosphate (cGMP) concentration in the isolated corpus cavernosum were analyzed by Western blotting.Peak ICP/MAP ratio was increased in the KBMSI-2 treatment group compared with the model group (P0.05). Masson's trichrome staining confirmed that the smooth muscle component was increased in the KBMSI-2 treatment group compared with the model group (P0.05). The nNOS, eNOS and cGMP expression of KBMSI-2 200 mg/kg treatment group was increased compared with the model group (P0.05).This study showed that herbal formula of KBMSI-2 improved the erectile function by preserving the smooth muscle content and inhibiting the fibrosis of the corpus cavernosum in STZ-induced diabetic rat model.

of the PC away from normal renal parenchyma) is classically used for familial Renal Cell Carcinoma (RCC) but has not been widely adopted for sporadic RCC. We investigate whether tumor histology predicts the presence, thickness, and extension of tumor through the PC, potentially identifying tumors best suited for a TE nephron-sparing approach. METHODS: Twenty-five consecutive total or partial nephrectomies for pT1 clear cell, papillary, chromophobe, and oncocytoma were included (N 100 total tumors). Specimens were reviewed for numerous pathological features including stage, grade, lympho-vascular invasion, as well as characteristics of PC such as capsular presence/ absence, mean thickness, continuity, and tumor capsule invasion (TCI). PC parameters (thinnest, thickest and mean) were calculated from multiple measurements using an ocular micrometer, rounded to the nearest tenth of a millimeter. RESULTS: Tumor sizes in each group were similar. PC was complete in: papillary (n 21, 84%), clear cell (n 19, 76%), chromophobe (n 7, 28%), and oncocytoma (n 1, 4%); present but incomplete in oncocytoma (n 14, 56%), chromophobe (n 11, 44%), clear cell (n 6, 24%), and papillary (n 2, 8%); and absent in oncocytoma (n 10, 40%), chromophobe (n 7, 28%), papillary(n 2, 8%), and clear cell (0%). TCI was seen in 30% of papillary and only 8% of clear cell (p-value 0.006) PC. When present, mean thickness of the PC was significantly thicker for clear cell (0.8mm) when compared to the other tumors (papillary and chromophobe 0.6mm and oncocytoma 0.3mm). Multivariate logistic regression demonstrated only tumor type to be significantly associated with TCI (p-value 0.046, OR 10.3 (95%CI)). CONCLUSIONS: In pT1 renal tumors, PC appears predictable based on tumor histology. The PC is likely to be absent or incomplete in renal oncocytoma and chromophobe. Papillary RCC demonstrates the highest % of TCI which could predict higher surgical margin rates during TE surgery. Clear cell RCC possesses the thickest, most complete tumor capsule with minimal TCI and may be best suited for TE partial nephrectomy.

Objective: The aim of this study was to evaluate the effect of cyanidin-3-O-β-D-glucopyranoside (C3G) concentrated materials from mulberry fruit on improvement and protection of erectile function. Materials and Methods: Sprague-Dawley rats (12 weeks old) were divided into three groups (n = 12 in each): normal control, diabetes mellitus (DM), and DM with C3G concentrated material treatment (DM + C3G). DM and DM + C3G group rats received a single injection of streptozotocin (50 mg/kg), and 4 weeks after induction of diabetes, the DM + C3G group rats were treated with daily concentrated material treatment (10 mg/kg) dissolved in water for 8 weeks. After 12 weeks of streptozotocin injections, the rats in each group underwent intracavernosal pressure measurement and then the corporal tissues were sampled. Results: The DM group rats showed markedly lower erectile parameters than those in the control group, whereas rats in the DM + C3G group showed improved erectile function by minimizing corporal apoptosis and increasing the expression of endothelial nitric oxide synthase (NOS) and neuronal NOS protein. A significant increase in 8-hydroxy-2-deoxyguanosine (8-OHdG) was shown in the DM group compared with the normal group. However, in the DM + C3G group, 8-OHdG was statistically significantly reduced compared with the DM group. Conclusions: The current study is the first to suggest that C3G concentrated materials may have a potency to improve and protect erectile function under conditions of diabetes-induced oxidative stress.

PURPOSE Recently, as the number of transobturator tape (TOT) procedures has increased, recurrence after this procedure has been frequently reported. However, there are no standard guidelines for treatment. We describe our experience with shortening the previously implanted tape in patients with recurrent stress urinary incontinence after the TOT procedure. MATERIALS AND METHODS We enrolled 10 women who underwent shortening of the previously implanted tape and were followed up for 3 years. Shortening of the previously implanted tape was done by a figure-eight suture with 1-0 Prolene. One year after TOT shortening, we investigated continence status, patient satisfaction by means of a questionnaire, maximal flow rate (Qmax), and postvoid residual urine volume. Three years after TOT shortening, we evaluated continence status and patient satisfaction. RESULTS The mean period of TOT shortening was 4.2 months (range, 1-12 months) after the TOT procedure. One year after TOT shortening, 7 patients showed complete dryness, 2 patients showed improvement, and 1 patient reported failure. Eight patients were very satisfied or satisfied with the 1-year result after TOT shortening. The mean preoperative and postoperative Qmax were 23.8 and 26.7ml/s, respectively, and there was no significant difference. Three years after TOT shortening, 6 patients showed complete dryness, 2 patients showed improvement, and 2 patients reported failure. Among them,1 had failed from 1 year after TOT shortening and the other had shown 1 year of complete dryness. Eight patients were very satisfied or satisfied and 2 patients were dissatisfied with the 3-year result after TOT shortening. CONCLUSION Most of the patients who underwent TOT shortening reported satisfaction as well as improvement of incontinence after a 3-year follow up. Therefore, we suggest that TOT shortening may be recommended primarily in patients with recurrent stress urinary incontinence after the TOT sling procedure.