Purpose: Despite refinements in the surgical techniques for adult-to-adult living donor liver transplantation (ALDLT), biliary complications still remain the Achilles' heel of ALDLT. Moreover, there is no consensus for the ideal technique of biliary reconstruction to reduce the rate of complications to an acceptable range. We strove to collate the available data of the current surgical techniques for biliary reconstruction in ALDLT in Korea. Methods: A questionnaire concerning the surgical techniques for biliary reconstruction was sent to 9 surgeons who performed biliary anastomosis in the major LDLT centers of Korea (the response rate was 100%). Results: MR cholangiography (n=7) and/or intra-operative cholangiography (n=5) were routinely performed to evaluate the donor biliary anatomy. All the participants (n=9) preferred duct-to-duct anastomosis to hepatico-jejunostomy. Anastomosis was usually made on the whole layer (n=7 epithelium, n=2) of recipient's common hepatic duct under loupe magnification (n=8); only one center reconstructed the anastomosis on the $2^{nd}$ order hepatic duct under view of a surgical microscope. There were various techniques for biliary reconstruction as follows: suture material (absorbable: n=5, non-absorbable: n=4), suture method (continuous: n=4, interrupted: n=3, mixed: n=3) and the use of a biliary stent (routine: n=3, sometimes: n=5, rare: n=1). Ductoplasty was performed on the back table (n=7) for the cases with a very close distance (<5 mm) between the bile ducts' openings, but each duct was separately anastomosed to the recipients' bile duct (n=8) or a roux-en-Y limb (n=1) was done in cases with a distance more than 10 mm. Conclusion: In 9 LDLT centers of Koreas, duct-to-duct was preferred; however, there was no unique consensus, among the major centers, for the biliary reconstruction techniques that might reduce complications.

Purpose: A few studies have been reported on extrahepatic metastasis after curative resection for hepatocellular carcinoma (HCC). We investigated the patterns of extrahepatic recurrence and we identified the risk factors for extrahepatic recurrence after curative resection for HCC. Methods: We retrospectively reviewed 587 patients who underwent surgical resection with a curative aim from January 1998 to December 2007 in the Yonsei University Health Care System. Among the 571 patients, 291 (51.0%) patients developed recurrence. Sixty five patients initially presented with extrahaptic recurrence. The patients with extrahepatic recurrence were divided into Group A (peritoneal recurrence) and Group B (non-peritoneal extrahepatic recurrence). Results: Group A had higher rates of intraoperative bleeding>1,500 ml and perioperative transfusion too. On the multivariate analysis, perioperative transfusion, satellite nodule and the tumor size were the independent risk factors for Group A. The Edmondson-Steiner grade, satellite nodule and the tumor size were the independent risk factors for Group B. The 1, 3 and 5-year overall survival rates after curative resection for the patients with extrahepatic recurence were 83.1%, 48.9% and 27.4%, respectively. The recurrence patterns and treatment modalities did not affect the overall survival after treatment for extrahepatic recurrence. Conclusion: A perioperative transfusion was found to be a different risk factor for peritoneal recurrence, as compared to those risk factors for non-peritoneal extrahepatic recurrence. Therefore, efforts by physicians to decrease intraoperative bleeding may prevent peritoneal recurrence after performing curative resection for HCC.

Purpose: Graft-Versus-Host Disease (GVHD) is a rare (0.1~2%) but severe complication after liver transplantation (LT). It is the most lethal complication after LT and there are currently no effective preventive or therapeutic measures available. Approximately 90 such cases have been reported in the literature, but only one case has been reported in Korea. Methods: We performed a retrospective analysis of 767 patients who underwent LT (living donor : deceased donor=554 : 213) at Seoul National University Hospital, Korea from 1998 to 2009. Four patients (4/767, 0.52%) with histologically proven GVHD were found. The diagnosis of GVHD was made according to observing macrochimerism in the peripheral blood and the affected tissue biopsy. Results: Four patients underwent LT due to Hepatitis B virus-related liver cirrhosis and two of these patients had coexisting hepatocellular carcinoma. Three patients received livers from deceased donors and one received a liver from a live donor. All their blood matching were identical. The first diagnosed case underwent human leukocyte antigen (HLA) typing only after LT and it showed complete one-way donor-recipient HLA matching. The onset of GVHD occurred between 10 days and 55 days after LT. All the patients developed high-grade fever, skin rash, neutropenia, diarrhea and the main signs and symptoms related to GVHD. All the patients died because of sepsis despite intensive treatment. Conclusion: GVHD after LT is an extremely rare and fatal complication and it is difficult to diagnose. Therefore, we should perform pre-transplant HLA matching and try to establish an early diagnosis for patients who are clinical suspicious of having GVHD. Further study in this area is needed and physicians need to be alert to detect this malady.

Purpose: The goal of this article was to characterize and explain the etiology of a left-sided gallbladders with intrahepatic portal vein anomalies, and these cases of this unusual anatomy were all encountered at a single center. Methods: We reviewed the movies recorded during surgery, the database information and the preoperative radiologic examinations of 1,141 patients who underwent cholecystectomies at our institution between August 2007 and July 2010 to assess the presence of left-sided gallbladder and its combined anomalies. Results: Four of 1141 patients (0.35%) were diagnosed with left-sided gallbladder. In all the cases, the gallbladder was located on the left side of the falciform ligament, under the left lobe of the liver with typical abnormal intrahepatic portal venous branching. The right posterior portal vein came directly from the main portal vein, and the right anterior portal vein originated from the left portal vein, but the ligamentum teres joined to the left branch of the portal vein in the liver. Conclusion: Left-sided gallbla dder with intrahepatic portal venous branching anomaly resulted from the defective development of the central portion of the liver rather than from abnormal regression of the left umbilical vein with persistence of the right umbilical vein.

Purpose: We would like to assess the safety and feasibility of extended spleen-preserving distal pancreatectomy with segmental resection of both splenic vessels (SPDP-SRSV) in patients with large, benign and borderline malignant pancreas body tumors. Methods: We encountered seven extended SPDP-SRSV cases from January 2006 to March 2010. Among them, three were excluded due to combined pylorus-reserving pancreaticoduodenectomy (PPPD). For the extended surgical technique, the pancreas was divided above the confluence of the superior mesenteric vein-splenic vein-portal vein (SMV-SV-PV), and vascular control was achieved at the origin of the splenic artery and the junction of the splenic vein with the SMV. The segments of both splenic vessels were then extracted along with the specimen. Results: All the patients were female with a median age of 57 years (range: 24~70 years). The median tumor size was 5.5 cm (range: 5~11 cm), the median operation time was 362 minutes (range: 337~441 min), the median estimated blood loss was 150 ml (range: 50~300 ml) and the median hospital stay was 9 days (range: 7~20 days). One patient underwent robot-assisted extended Warshaw procedures. No mortality was noted, but one partial intestinal obstruction occurred and this was resolved with conservative management. On the recent follow-up, the CT scans showed no evidence of tumor recurrence or spleen infarction, but newly developed perigastric varix was noted, but it was without variceal bleeding. Conclusion: SPDP-SRSV with division of the pancreatic neck portion above the confluence of the SMV-SV-PV in patients with large, benign and borderline malignant pancreatic body tumors appears to be an ideal approach because of the expected long-term survival and preserving the role of the spleen.

Purpose: We wanted to evaluate the clinical effectiveness of intraoperative radiation therapy (IORT) in combination with external beam radiation therapy (EBRT) for treating unresectable or metastatic pancreatic cancer. Methods: From August 1993 to July 2007, 28 patients with unresectable or metastatic pancreatic cancer received IORT (median: 20 Gy) combined with or without EBRT (median: 50.4 Gy). Eighteen patients were treated with IORT followed by EBRT, and 10 patients were treated by IORT alone. Eighteen patients underwent explolaparotomy and 10 patients underwent bypass surgery. Results: The 1-year overall survival rate (OS) and the median survival time of all 28 patients were 21.4% and 7.5 months, respectively. The 1-year OS and median survival time for the clinical stage III patients were 33.3% and 10.2 months, respectively, and they were 7.7% and 5.1 months for the clinical stage IV patients, respectively (p=0.007). Univariate analyses revealed that the stage, chemotherapy and tumor volume were the significant prognostic factors for OS. The patients treated with IORT combined with EBRT had a more favorable 1-year local control rate than that of those patients treated with IORT alone (88.9% vs. 50.0, respectively, p=0.009). But the significant improvement in local control did not translate into a survival benefit. The addition of EBRT was an independent prognostic factor for improving the local control rate. The operative mortality was 0%. Conclusion: IORT combined with EBRT is considered to be effective in achieving local control and palliation for patients with unresectable or metastatic pancreatic cancer. Further, IORT seems to be safe and it does not increase the mortality or the incidence of surgical wound infection.

A 65-year old man underwent wedge resection for a gastrointestinal stromal tumor (GIST) of the gastric fundus in 1997. In 2003, the abdominal CT and sono-guided biopsy revealed he had a large GIST liver metastasis. He underwent treatment with 400 mg/day of imatinib mesylate. As a result, the liver metastasis markedly decreased in size. However, focal progression of the liver metastasis was observed on the follow up CT, so we increased the imatinib from 400 mg/day to 800 mg/day. We then performed extended left hepatectomy. We report here on a patient who presented with an isolated metastatic GIST to the liver, and the patient was successfully treated with imatinib therapy and hemihepatectomy.

Pancreatic fistula is the most frequent complication after pancreatic resection regardless of the extent of the resection. A 68-year-old woman with B-viral hepatitis was referred with an incidentally detected pancreatic head mass that was diagnosed 4 months previously when performing following up of her liver cirrhosis. She had no specific symptoms, but she had a 1.2 cm sized solitary mass that was suspected to be a pancreatic endocrine tumor and it was located very close to the main pancreatic duct in the pancreas uncinate process on the imaging workup. Preoperative endoscopic pancreatic stenting was prepared to guide the enucleation of the mass while identifying the pancreatic duct using intraoperative ultrasonography. Precise intraoperative estimation of the mass and the pancreatic duct was possible and the enucleation was successful without injury to the duct. We recommend this operative approach especially when planning local pancreatic resection for tumors in the pancreatic head or uncinate process, as these tumors make the pancreatic duct vulnerable to injury.

Hamartoma of the spleen is a rare benign lesion and the pathogenesis of this is not completely understood. It is usually incidentally discovered during an operation or autopsy. Since the first report in 1861 by Rokitansky, less than 150 cases of splenic hamartoma have been documented in the literature to date. The majority of the patients with this tumor are asymptomatic. However, a few of these lesions are associated with clinical features such as hypersplenism, cirrhosis of the liver and spontaneous splenic rupture. Because there are no specific symptoms, tumor markers or radiologic results, it is usually difficult to make a diagnosis before surgery and the specimen pathology. We report here on three cases of splenic hamartoma (a 33-year-old man associated with thrombocytopenia, a 29-year-old woman with a 6-month history of left upper quadrant abdominal pain and a 43-year-old man with synchronous hepatocellular carcinoma) and we review the relevant literature.

Mirizzi syndrome refers to a gallstone impacted in the gallbladder neck and this exerts pressure on the adjacent common hepatic duct, which produces inflammatory stricture and eventual penetration of its lumen. Making the preoperative diagnosis of Mirrizzi syndrome is very important. But if it cannot be diagnosed before an operation, intraoperative recognition is also important for surgeons. We experienced two patients who were diagnosed with this syndrome at the time of operation.