Purpose: Cell therapy for various diseases has gained wide acceptance. Because most patients with chronic liver failure have mild-to-severe liver cirrhosis, there are many limitations to clinical applications. We analyzed how to increase cell engraftment in rats with liver fibrosis. Methods: We used analbuminemic SD rats (NARs) as recipients of syngeneic CAG-EGFP SD hepatocytes obtained by the 2 perfusion method. Hepatic fibrosis was induced with thioacetamide in drinking water for 6 weeks in the recipient NARs. NARs were pre-treated with gadolinium, doxorubicin, and gliotoxin before hepatocyte transplantation. We evaluated the degree of cell engraftment by RT-PCR and immunofluorescent staining for GFP and albumin. The transplanted cells were detected by immunostaining for albumin, and serum albumin was also measured. Results: Although detection of GFP by RT-PCR was variable, albumin was detected in all groups 4 wks after hepatocyte transplantation. GFP and albumin were also detected by immunofluorescent staining 1 and 4 wks after cell transplantation. In control rats, albumin production was maximal at 3 wks, and after that it rapidly decreased. In the gadolinium and doxorubicin-treated group, albumin production was increased up to 4 wks. Albumin production in the gadolinium-treated group was superior to that of the doxorubicin-treated group. Conclusion: Kupffer cells play the most important role in cell engraftment in hepatic fibrosis. Therefore, perturbation of kupffer cells in hepatic fibrosis is needed to increase cell engraftment.

Purpose: Human mesenchymal stem cells (hMSCs) have the potency for self-renewal and differentiation into various kinds of cells. The hMSCs are obtained from the various tissues, including adipose tissue, bone marrow and cord blood. The extracellular matrix (ECM) is an important factor that affects cell adherence, growth, migration, apoptosis and differentiation both in vitro and vivo. The adipose-derived mesenchymal stem cells (AD-MSCs) have CD29 (integrin) on the cell surface, which is the receptor for fibronectin. The aim of this study is to validate the efficacy of ECM, and especially fibronectin, for cell expansion. Methods: The AD-MSCs were obtained from the abdominal fat of humans. These cells were seeded onto culture plates coated with fibronectin-Human (FN) and plates without ECM (control). The cells were incubated for 3 passages and the cellular morphology was simultaneously observed with microscopy. CCK-8 assay was performed to compare the proliferation ability in each condition at the same passage. Immunocytochemistry staining for integrin-beta1 was performed to observe the cell to cell interaction. Results: The hAD-MSCs in the FN-coated and non-coated plates exhibited cytoplasm staining for integrin-beta1. In all the cultures, extended fibroblastic-shaped cells that turned into rhomboid cells were most frequently observed. The cell growth rates for the non coated culture plate were lower than those for the FN coated plates. After 72 hour culture under the different coated concentrations of FN and the non coated condition (control), the control group had a lower growth rate. In the culture with a FN coated plate, a significant change was observed as compared with that of the control group. We observed an increase in cell proliferation, with a maximum of 140%, on the FN coated plate by performing CCK-8 assay. In comparison, integrin ${\beta}1$ on the cells was more expressed in the FN-coated plates than that in the non-coated plates. Conclusion: The cell morphology can be changed faster in the FN coated culture plates than that in the non coated culture plates. Because proliferation and adhesion with FN can enhance the expansion, the culture within a FN coated plate is needed to encourage hAD-MSCs to proliferate in vitro.

Purpose: The most important consideration for therapy using MSCs is the differentiation of the target organ's cell type. For in-vitro hepatogenic differentiation of MSCs, the main focus is efficient induction of the MSCs into the endoderm stage. Activin A, which is a signaling molecule that is similar to Nodal, promotes the induction of definitive endoderm from both ESs and MSCs. The protocols for induction into definitive endoderm have shown different efficiency and reproducibility depending on the researchers or the sources of the MSCs. Thus, a study on the various conditions of Activin A is needed to efficiently differentiate MSCs into the definitive endoderm lineage of MSCs. Methods: MSCs were isolated from human adipose tissues and these were cultured in MCM (MSCs Culture Medium) on a human fibronectin coated plate. At 70~80% confluence, the MSCs were harvested and cultured in MCM supplemented with Activin A, at a 50 ng/mL concentration, and FGF4. The expression of the genes related with MSCs or primitive endoderm were analyzed by RT-PCR. The changes of cell morphology for differentiation were also observed by a light microscope & a SEM. Results: The expression of genes related with primitive foregut endoderm was seen in the groups that were treated with a higher concentration of Activin A. The morphology of the cells that differentiated into definitive endoderm were not different from those of the undifferentiated MSCs. The expression of genes related with functional primitive hepatocytes was seen in the early phase during hepatic differentiation. The cell morphology was changed to a similar cuboidal form in a time-dependent manner. Conclusion: Activin A promotes a more rapid induction of definitive endoderm. It also makes an efficient condition for the differentiation into primitive foregut endoderm at a higher concentration.

Purpose: There has been controversy concerning which is the best treatment method for small hepatocellular carcinoma between anatomical resection (AR) and non-anatomical resection (NAR). In this retrospective study, we investigated the outcomes of surgical resection for small hepatocellular carcinoma and the clinical results depending on the type of hepatectomy. Methods: We performed an analysis of the clinicopathologic factors of forty eight patients who underwent hepatectomy for a small (<2 cm) hepatocellular carcinoma between 1990 and 2005. The AR was defined as the resection based on the segment or lobe, as proposed by Couinaud. NAR was defined as the resection of a lesion without regard to the segmental or lobar anatomy, as proposed by Couinaud. The patients were divided into 2 groups base on the hepatectomy procedure: AR (n=24) and NAR (n=24). Results: There were no significant difference between the two groups for the general characteristics of the patients and the clinicopathologic findings, except for ICG R15. The mean ICG R15 in the AR and NAR groups was $11.8{\pm}6.9$ and $22.4{\pm}15.6$, respectively, The NAR group had significantly higher ICG R15 values. The cumulative 1, 3 and 5 year overall survival rates in the AR and NAR groups were 95.8%, 68.2% and 61.3%, and 76.6%, 59.0% and 52.5%, respectively. The cumulative overall survival rate and the mean 5 year disease free survival rate in the AR group (69.8%) were higher than those of the NAR group (45.8%). However, there was no statistically significant difference. Conclusion: Depending on the surgical results of this study, there was no statistically significant difference in the outcomes between the AR and NAR groups.

Purpose: Although laparoscopic liver resection has become popular and it has shown good surgical safety and feasibility, the oncologic safety is still not established. Therefore, we analyzed the mid-term survival and disease free survival rates after laparoscopic liver resection for HCC to establish the oncologic safety. Methods: Between September 2003 and August 2008, 64 patients with hepatocellular carcinoma underwent laparoscopic liver resection. The clinical data of these patients was analyzed by the Kaplan-Meier method. Results: There were 19 major hepatic resections and 45 minor hepatic resections without any mortality. There were 15 complications, including 9 cases of abdominal fluid collection, 3 cases of bile leakage, 2 cases of ascites and 1 case of ileus. The 3 years overall survival and disease free survival rates were 87.8% and 67.3%, respectively. Conclusion: We confirmed that laparoscopic liver resection for hepatocellular carcinoma is safe and feasible. The 3 years survival rates and disease free survival rates were as high as those of open resection for hepatocellular carcinoma.

Purpose: Hepatic resection is the standard treatment for hepatocellular carcinoma (HCC). In some patients with multiple HCC, one-block resection is not feasible due to either the tumor location or the underlying liver function. In this study, we attempted to compare the outcomes of multiple - site resection or combined resection and radiofrequency ablation with those of one-block resection in patients with multiple HCC. Methods: We retrospectively reviewed 507 patients who underwent surgical resection. Among 507 patients who received surgical treatment with potentially curative aim from January 1996 to August 2006 in Yonsei University Health System, 58 patients had a radiologically detected multiple HCC. Patients with multiple HCC were divided into: group A, patients treated with one-block resection (n=40) and group B, patients with multiple-site resection or combined resection and RFA (n=18). Results: The 1-, 3- and 5-year overall survival rates for patients with single and multiple HCC were 90.2%, 76.2% and 66.7% and 82.7%, 61.4% and 37.9%, respectively (p<0.001). In group B, 6 patients received multiple-site resection and 12 patients underwent combined resection and RFA. The clinicopathological variables were not significantly different between the two groups except the distribution of multiple tumors. The postoperative complication rates for group A and B were 32.5% and 33.3%, respectively. The 1-, 3- and 5-year disease-free survival rates for group A and B were 53.0%, 27.6% and 24.1% and 18.3%, 24.1% and 18.3%, respectively (p=0.386). The overall survival rates were also not significantly different between the two group (80.0%, 59.6%, and 36.9% for group A and 88.9%, 65.7% and 39.4% for group B, p=0.528). The multivariate analysis revealed that Edmondsons-Steiner grade (III-IV) and Indocyanine green retention rate at 15 minutes (ICG R15) >10% were adverse prognostic factors for overall survival. Conclusion: Active treatments including multiple-site resection and combined resection and RFA showed similar treatment outcomes compared with one-block resection in patients with multiple HCC.

Purpose: We wanted to evaluate the influence of preoperative non-surgical treatment and its duration for hepatocellular carcinoma (HCC) patients who underwent liver transplantation (LT). Methods: We analyzed 75 patients with HCC who underwent living donor liver transplantation from January 1999 to December 2005. The median follow-up was 40.2 months. The patients were divided into the not treated group (26 patients) and non-surgically treated group (49 patients). We compared the overall survival (OS) and disease-free survival (DFS) rates of the 24 not treated patients with that of the 33 treated patients within the Milan criteria. The treated group was divided to 39 short-term (<3 years) treated patients and 10 long-term (${\geq}3$ years) treated patients by the preoperative treatment duration. The OS and DFS rates were analyzed. Results: For 57 patients within the Milan criteria, the 1-, 3- and 5-year OS rates and the 1-, 3- and 5-year DFS rates were 80.0%, 68.5%, 64.8%, 82.0%, 77.2% and 75.1%, respectively. There were no different characteristic between the not treated group and the treated group, except for the mean age and the Child-Turcotte-Pugh score. Compared to the treated group, the OS and DFS rates were slightly better in the not treated group (p=0.053). There were more patients who underwent transcatheter arterial chemoembolization only in the short-term treated group and there were more patients who had microvascular invasion in the long-term treated group. The OS and DFS rates showed no significant difference between the two groups. Conclusion: It is possible that LT is a first treatment for HCC patients. If the patients' response to preoperative treatment was good, then their prognosis may be same regardless of the treatment duration.

Purpose: Splenectomy during living donor liver transplantation (LDLT) in a hepatitis C virus (HCV)-related cirrhotic recipient was performed by a Tokyo group to enhance the patient's tolerability to post-operative anti-viral treatment by improving complete blood count (CBC) profiles. At our institution, interruption of the splenic artery (SPA) by ligation or embolization in lieu of splenectomy, has been performed in LDLT to modulate portal blood flow in small-for-size graft LDLT or to prevent rupture of SPA aneurysms in recipients. We aimed to determine if interruption of the SPA can serve as an alternative management to splenectomy in LDLT recipients based on our data. Methods: Patients were classified into the splenic artery ligation group (SAL; n=26) and splenic artery embolization group (SAE; n=19), respectively. Among the recipients without SPA interruption, age-, gender-, and severity of cirrhosis-matched 25 recipients were selected as a control group. Post-operative CBC profiles and spleen size were reviewed retrospectively and compared between the groups. Results: After SAL, platelet and neutrophil counts were significantly increased at 3 and 6 months, and at 1 week and 1 month, respectively (p<0.05). After SAE, platelet and neutrophil counts were significantly increased at 3 and 6 months, and at 1 week and 3 months, respectively. There were no significant complications related to interruption of the SPA. Conclusion: Interruption of the SPA may have a role in improving neutrophil and platelet counts in LDLT recipients with severe pancytopenia or in whom antiviral treatment for HCV in anticipated.

Purpose: Liver transplantation (LT) has been advocated as a good management option for patients with hepatocellular carcinoma (HCC). The rate of HCC recurrence after LT is about 20%. Although the median survival time of patients with HCC recurrence is 7~9 months, the role of surgical treatment for metastatic tumors has been reported on. In this study, we evaluated the role of metastasectomy for treating patients with pulmonary metastasis from HCC after LT. Methods: We retrospectively analyzed 10 patients with pulmonary metastasis after LT and who were treated between April 2005 and October 2007. The underlying liver disease was cirrhosis caused by chronic viral hepatitis. The surveillance protocol for HCC recurrence was as follows:assessing the serum alpha-fetoprotein level every 1 month, chest and abdomen-pelvic computed tomography every 3 months and a bone scan every 1 year or when bone metastasis was suspected. The patients with less than 3 metastatic lesions were recommended to undergo metastasectomy (Group S, n=6) and the patients with more 4 lesions were recommended nonsurgical management, including chemotherapy (Group N, n=4). Results: All the metastatic lesions were detected on the protocol chest CT scans. The median recurrence time was 7.4 months (0.8~18.2) after LT; this was 11.0 (4.8~18.2) months for Group S and 2.0 (0.8~3.3) months for Group N. One patient had a single lesion and the others had multiple lesions on multilobes. The median survival times of Group S were 29.3 (18.5~41.3) months after pulmonary metastasis and 40.3 (23.3~48.0) months after transplantation; 5 patients had no recorded evidence of their disease status. The median survival time of Group N was 4.3 (4.0~6.3) months after metastasis and 6.2 (5.3~7.1) months after transplantation; all the patients have since died. Conclusion: The survival outcome seemed to be good for the patients who underwent pulmonary metastasectomy for HCC, if it was detected earlier and it was resectable (${\leq}3$ lesions). However, further study is required for validating the survival benefit of pulmonary metastasectomy.

Purpose: In spite of its safety and fesibility, it is not completely certain whether two-port laparoscopic cholecystectomy can be applied for the same indications as four-port cholecystectomy. Methods: We retrospectively analyzed the prospectively collected data of the patients who had undergone either two-port or four-port laparoscopic cholecystectomy at the Department of Surgery, Daejeon St. Mary's Hospital between March 2007 and August 2009. A total of 341 patients were included. For our two-port cholecystectomy, combining a transumbilical wound retractor with a surgical glove on which there was a 11 mm trocar and two pipes were attached comprised an umbilical common channel, and another port was inserted through the epigastrium. The overall procedure was similar to four-port laparoscopic cholecystectomy. Results: The patients were classified into the four-port group (n=261) and the two-port group (n=80) according to the operative method. All the two-port cholecystectomies were followed by four-port procedures. The operative indications for these two procedures were identical. No significant difference was observed for the mean operation time, the conversion rate, the postoperative hospital stay and the complications between each group. Multivariate analysis revealed that the factors making two-port surgery longer than the 75 percentile of the overall operation time were the development of intraoperative complications (RR 14.3; p=0.005; C.I. 2.255-90.853), a operation for the patients who visited the emergency room (RR 10.4; p=0.012; C.I. 1.684-63.798), open conversion or making additional port(s) (RR 9.9; p=0.032; C.I. 1.219-80.958) and a body-mass index greater than 25 (RR 5.5; p=0.025; C.I. 1.244-24.731). Conclusion: This study documents that our two-port laparoscopic cholecystectomy seems to have the potential to replace the conventional four-port laparoscopic cholecystectomy.

Purpose: Choledochal cysts are rare congenital or acquired cystic dilatations of the intra- or extra-hepatic bile ducts. The mechanism of carcinogenesis in choledochal cyst has not been clearly elucidated, although stasis of bile and reflux of pancreatic juice appear to be important factors. The aim of this study was to identify the clinical risk factors predicting development of biliary tract cancers in patients with choledochal cyst. Methods: The study subjects included 170 consecutive patients who underwent surgery for choledochal cysts at Seoul National University Hospital between December 1980 and May 2008. We analyzed the demographic characteristics, clinical symptoms, laboratory findings, type of choledochal cysts, pathologic characteristics, and long-term outcomes of the patients with associated biliary tract cancers. Results: Out Of 170 patients with choledochal cysts, combined biliary tract cancers ware identified in 29 patients, which included extrahepatic bile duct (n=15; 51.7%), gallbladder (n=12; 41.4%), and ampulla of Vater cancers (n=2; 6.9%). There were no significant differences in gender, clinical symptoms (abdominal pain, jaundice, and abdominal masses), laboratory findings (leukocytosis, hyperbilirubinemia, and increased alkaline phosphatase), and Todani classification of choledochal cysts between the two groups with or without combined biliary tract cancer. Multivariate analysis revealed that age ${\geq}41$ years and pancreatico-choledochal type APBDU were associated with the development of biliary tract cancers in patients with choledochal cysts. Conclusion: Age ${\geq}41$ years and pancreatico-choledochal type APBDU were associated with the development of biliary tract cancers in patients with choledochal cysts. Therefore, the possibility of associated biliary tract cancers should be considered when planning surgical management for patients with these risk factors.

Purpose: Insulinomas and nesidioblastosis are surgically curarable hyperinsulinemic hypoglycemic diseases; however the symptoms, diagnosis, and localization of these diseases are sometimes difficult. Methods: From April 1990 to December 2008, patients with diagnosis of pancreatic insulinoma and nesidioblastosis were retrospectively reviewed. Results: In the entire cohort, there were 6 patients with multiple endocrine neoplasia type 1 (MEN 1), 7 patients with nesidioblastosis, and 7 patients with multiple lesions. The incidence of neuroglycopenic symptoms (71.5%) was more prevalent than autonomic symptoms (26.5%). The pre-operative localization methods were computed tomography (CT), transabdominal ultrasonography, endoscopic ultrasonography (EUS), magnetic resonance imaging (MRI), angiography, selective arterial calcium stimulation with venous sampling (ASVS), and transhepatic portal venous sampling (THPVS) which had sensitivities of 75%, 40%, 75%, 64%, 48%, 20%, and 87%, respectively. During the second half of the study period, CT had a sensitivity of 83%. THPVS was the most sensitive method of all the diagnostic tools. Intra-operative palpation and ultrasonography were the most powerful modalities for tumor localization. The surgical treatments included enucleation (20%), distal pancreatectomy (51%), central pancreatectomy (12%), pancreaticoduodenectomy (15%), and near-total pancreatectomy (1.5%). From 2006, laparascopic surgery was used as the preferred treatment modality for insulinomas. Conclusion: Early diagnosis and precise localization is the most important aspect of treating insulinomas. For better localization, dual phase spiral CT and intra-operative ultrasonography play an important role in tumor localization.

Purpose: Pancreatic fistulas are a leading cause of mortality and morbidity following pancreaticoduodenectomy. The objective of this study was to evaluate the possibility of controlling pancreatic fistula formation by binding pancreaticojejunostomy into the operative procedure, as proposed by Peng, which results in a 3 cm invagination of the pancreatic remnant by the jejunal segment bearing electrically-destroyed mucosa reinforced by inner and outer sutures. Methods: Prospectively collected data of patients undergoing pancreaticoduodenectomy in the Department of Surgery of Daejeon St. Mary's hospital between April 2007 and May 2009 were analyzed retrospectively. Thirty-one patients were included in the study; 16 patients underwent dunking pancreaticojejunostomy and 15 patients underwent binding pancreaticojejunostomy. Results: The two groups were comparable with respect to demographic data, pre-operative characteristics, underlying pathologies, pancreatic textures, and duct diameters. The mean operative time did not differ between the two groups ($388{\pm}29$ min vs. $459{\pm}21$ min, p=0.060). No difference existed in the post-operative course except for the degree of complications. In contrast to the dunking group, in which 2 cases of grade III/V pancreatic fistulas occurred, the binding group had no severe complications. In addition, transformation of amylase data measured from Jackson-Pratt drains into a natural logarithm demonstrated significant differences on post-operative (POD) days 1, 3, and 7 between the dunking and binding groups (POD1, $6.97{\pm}0.41$ vs. $6.10{\pm}0.44$ [p=0.037]; POD3, $6.97{\pm}0.41$ vs. $6.10{\pm}0.44$ [p=0.032]; POD7, $4.69{\pm}0.35$ vs. $3.88{\pm}0.25$ [p=0.034], respectively). Conclusion: Bindning pancreaticojejunostomy is equivalent to dunking pancreaticojejunostomy with respect to operative difficulties, and more effective in preventing complications related to pancreatic fistulas.

Non-surgical treatment is usually performed for the cases of hepatocellular carcinoma (HCC) that are not suitable for curative treatment, such as those cases with a large tumor size with an insufficient hepatic remnant after resection, those cases with extensive and multifocal bilobar tumors or those cases with extrahepatic metastases of the disease. However, in this case report we present a case of palliative hepatectomy for treating advanced HCC with multiple metastases and the patient has had an excellent 1-year follow-up outcome. A 71-year-old man was referred to our hospital and the imaging studies showed a 10 cm mass in the right liver, with multiple variable sized masses in both lungs and a 1 cm nodule in the left adrenal gland. A lung biopsy revealed HCC; therefore, the working diagnosis was HCC with multiple lung metastases and a left adrenal gland adenoma or metastasis. We expected the cause of death would be deterioration of the hepatic function as the liver mass increased in size. Therefore, we performed a palliative right trisectionectomy for the primary liver mass. After recovery from the hepatectomy, the patient was managed with sorafenib. During the 1-year follow-up period after palliative hepatectomy, the patient is still alive with a good general performance status and no evidence of intrahepatic recurrence, even though there has been an aggravation of the lung metastases in size and number, and a slight increase in the size of the left adrenal gland. We suggest that in highly selected patients with advanced HCC and multiple extrahepatic metastases, and especially in the cases involving a large HCC with mild liver cirrhosis and a good general performance status, an aggressive treatment strategy with palliative hepatectomy can be an optional treatment modality to improve the overall survival.

There is no consensus for the surgical indications, as well as the surgical technique, for the treatment of inferior vena cava (IVC) invasion by pancreas head cancer. The authors experienced a case of pancreas head cancer invading the anterior wall of the IVC. We performed en bloc excision of the anterior wall of the IVC combined with pancreatoduodenectomy in this case under the assumption that only a margin-negative surgical resection could offer a chance for cure. Technically, the sequence of dissection and addressing the IVC at the end of dissection are considered to be important to secure the operative field surrounding the IVC and to achieve a margin-negative resection. There has been no recurrence up to now, 8 months after the extensive radical operation.

Somatostatinoma is a rare endocrine tumor that comprises around 1% of all gastroentero-pancreatic endocrine neoplasm. The estimated annual incidence is 1 in 40 million. This tumor may be associated with von Recklinghausen's disease. We present here a rare case of a 51-year-old female patient with a duodenal nonfunctioning somatostatinoma combined with von Recklinghausen's disease. Whipple' procedure was performed. The postoperative course was uneventful and the histopathologic findings were consistent with malignant nonfunctioning somatostatinoma with lymph node metastases. The patient is alive, healthy and without tumor recurrence 10 months after surgery.