Published online before print March 13, 2003, 10.1148/radiol.2272011702
(Radiology 2003;227:407-413.)
© RSNA, 2003
Vascular and Interventional Radiology |
Preoperative Portal Vein Embolization with a New Liquid Embolic Agent1
Gi-Young Ko, MD,
Kyu-Bo Sung, MD,
Hyun-Ki Yoon, MD,
Jeong-Ho Kim, MD,
Young Cheol Weon, MD and
Ho-Young Song, MD
1 From the Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-Dong, Songpa-Ku, Seoul 138-736, Korea. From the 2001 RSNA scientific assembly. Received October 17, 2001; revision requested January 9, 2002; final revision received August 23; accepted August 27. Address correspondence to K.B.S. (e-mail: kbsung@amc.seoul.kr).
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ABSTRACT
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PURPOSE: To evaluate the effectiveness and safety of a new liquid embolic agent in preoperative portal vein embolization.
MATERIALS AND METHODS: Embol-78 was obtained by means of hydrolysis of polyvinyl acetate and was dissolved in a mixture of ethanol and nonionic water-soluble contrast medium. After percutaneous puncture of the portal vein, embolization of the right portal vein was performed in 22 patients with hepatocellular carcinoma and in 29 patients with nonhepatocellular carcinoma. In each group, changes in volume of the future liver remnant, portal venous pressure, and liver enzymes were evaluated both before and after embolization. Complications were also evaluated.
RESULTS: Portal vein embolization was successful in all patients, without major complications. The mean volumes of the future liver remnant before and 2 weeks after embolization were 385 mL ± 138 and 533 mL ± 140, respectively, in the hepatocellular carcinoma group and 517 mL ± 348 and 755 mL ± 197, respectively, in the nonhepatocellular carcinoma group. There were only transient elevations in liver enzyme levels after embolization. Mean portal venous pressures before and after the procedure were 16.7 mm Hg ± 3.8 and 20.3 mm Hg ± 3.6, respectively, in the hepatocellular carcinoma group and 11.7 mm Hg ± 3.5 and 14.6 mm Hg ± 3.6, respectively, in the nonhepatocellular carcinoma group. In each group, changes in volume of the future liver remnant and portal venous pressure were statistically significant (P < .001).
CONCLUSION: The liquid embolic material Embol-78 seems to be effective and safe for preoperative portal vein embolization.
© RSNA, 2003
Index terms: Liver, transplantation, 761.45 • Portal vein, stenosis or obstruction • Portal vein, therapeutic embolization, 957.1264
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INTRODUCTION
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Percutaneous transhepatic portal vein embolization has been an effective modality for the inducement of atrophy of embolized liver and compensatory hypertrophy of nonembolized liver, even in patients with impaired liver function (1–10). Hypertrophy of nonembolized liver reduces the possibility of hepatic failure after extensive liver resection. Although many embolic materials—including gelatin sponge particles, fibrin glue, cyanoacrylate glue, stainless steel coil, and ethanol—have been used for portal vein embolization, there appears to be no consensus as to which embolic material is the best (1–10).
Park et al (11) developed the liquid embolic material Embol-78 and proved its safety and effectiveness in an animal model. The purpose of the present study was to evaluate the effectiveness and safety of Embol-78 in human portal vein embolization.
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MATERIALS AND METHODS
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Embolic Material
The embolic material was obtained by means of the partial hydrolysis reaction of polyvinyl acetate (PVAc; Polysciences, Warrington, Pa) as described in the literature (11). Twenty grams of polyvinyl acetate were added into an Erlenmeyer flask with 172 mL of 99.9% acetic acid and 18 mL of distilled water, followed by addition of 10 mL of 36% hydrochloric acid as a catalyst for the hydrolysis reaction. After the reaction, the partly hydrolyzed polyvinyl acetate was precipitated in water and dried in a vacuum. Twelve grams of the precipitate were then dissolved in a mixture of 56 mL of Ultravist 370 (Schering Korea, Kyengki, Korea) and 44 mL of absolute ethanol. The solution was filtered through an 0.8-µm membrane filter into 10-mL vials and autoclaved. The concentration of iodine in Embol-78 solution was approximately 190 mg of iodine per milliliter.
Patients and Procedure
From September 1998 through March 2001, 51 patients (22 with hepatocellular carcinoma, 25 with cholangiocarcinoma, and four with gallbladder carcinoma involving the hepatic hilus) underwent percutaneous transhepatic portal vein embolization with Embol-78. Eleven of the 22 patients with hepatocellular carcinoma showed definite cirrhotic change on preprocedural computed tomographic (CT) scans. There were 37 men and 14 women, ranging from 27 to 69 years of age (mean age, 52 years). Informed consent was obtained from each patient, and this pilot study was approved by our university committee on human investigation. Twenty-four patients with cholangiocarcinoma and two patients with gallbladder carcinoma were jaundiced at admission, but only four patients were jaundiced at the time of percutaneous transhepatic portal vein embolization, since they had undergone percutaneous transhepatic biliary drainage. The planned resection procedure was right lobectomy in all patients.
Portal vein embolization was performed as an inpatient procedure after conscious sedation with use of intravenously administered Demerol (Keukdong Pharmaceuticals, Seoul, Korea) and Midazolam (Roche, Basel, Switzerland). Portal vein embolization was usually performed 2–3 weeks before surgery and was performed by one of the authors (G.Y.K., K.B.S., H.K.Y., J.H.K., Y.C.W.).
With fluoroscopic guidance, the right anterior or posterior portal vein was punctured percutaneously with a 21-gauge Chiba needle (Cook, Bloomington, Ind), and a 6- or 7-F sheath (Cook) was introduced into the portal vein. In two patients with large hepatocellular carcinomas in the right lobe, the left portal venous branch was punctured percutaneously. A 5-F cobra catheter was then inserted into the main portal vein through the sheath, and main portal and left portal venograms were obtained. Embolization of the right portal vein was achieved by embolizing the right anterior and posterior portal venous branches simultaneously through the side holes of a triple-lumen balloon catheter (Selecon multi catheter; Clinical Supply, Gifu-ken, Japan) after interruption of the right portal venous flow by inflating the balloon at the right portal trunk. Approximately 10 mL of 2% lidocaine was first infused through the side holes to prevent pain during embolization and was followed by a slow injection of Embol-78 through the side holes with the balloon inflated. If injection of Embol-78 was difficult because it solidified early, less than 1 mL of 30% ethanol was instilled into the catheter lumen to melt it, and additional Embol-78 was then injected.
In patients with portal venous trifurcation or a short right portal trunk, embolization was performed by first embolizing the right anterior portal venous branch with a double-lumen balloon catheter and then embolizing the right posterior portal venous branch. Since February 2001, the triple lumen balloon catheter has been unavailable; therefore, embolization has been achieved at our institution by embolizing the right anterior and posterior portal venous branches simultaneously through the lumen of the 7-F sheath after interruption of the right portal venous flow by inflating a balloon at the right portal trunk with an occlusion balloon catheter (Medi-Tech/Boston-Scientific, Boston, Mass). After all branches of the right portal vein were filled with Embol-78, an additional 1 mL of 30% ethanol was instilled into the catheter lumen to maintain catheter lumen patency, and the balloon was kept inflated for 10–15 minutes to allow the Embol-78 to solidify. With the balloon deflated slightly, it was confirmed that there was no reflux of Embol-78 into the main or left portal vein. The balloon was then deflated completely, and the catheter was removed. After postembolization main portal venography with a cobra catheter to verify embolization status and complications, the parenchymal tract was embolized with stainless steel coils. Portal vein pressure was checked in all patients both before and after embolization. Patients required 1–2 hours of bed rest after the procedure.
Follow-up
Body temperature, serum total bilirubin levels, and liver enzyme levels—including aspartate aminotransferase and alanine aminotransferase—were followed-up in all patients preprocedurally and at 2, 7, and 10 or 14 days following portal vein embolization. All patients also underwent (a) Doppler ultrasonography (US) 1 week after embolization to verify the embolized portal venous branches and (b) spiral CT 2 weeks after embolization to evaluate liver volume changes. Changes in liver volume were determined by means of volumetric study with contrast-enhanced CT (Somatom Plus; Siemens, Erlangen, Germany). Serial transverse scans at 8-mm intervals from the dome of the liver to the most inferior part of the liver were obtained and stored in a picture archiving and communication system, or PACS (Radpia; Hyundai Information Technology, Seoul, Korea). Operator-defined (G.Y.K.) free-hand regions of the future liver remnant were drawn on the PACS monitor, and the volume of the future liver remnant was calculated automatically by multiplying the area of the left lobe in each image by the interval thickness and by adding all the interval volumes of each part.
The following parameters were documented retrospectively: technical success, technical limitations, volume of injected Embol-78, and complications. Changes in the liver enzymes, volume of the future liver remnant, and main portal venous pressure in the hepatocellular carcinoma and nonhepatocellular carcinoma groups were also compared to evaluate differences in the effect of portal vein embolization.
Statistical Analysis
All data were expressed as mean ± SD. The paired Student t test was used to analyze differences in liver function tests, portal venous pressure, and volume of the future liver remnant both before and after portal vein embolization. The unpaired Student t test was used to analyze differences in regeneration rate of the future liver remnant and changes in main portal venous pressure between the hepatocellular carcinoma and nonhepatocellular carcinoma groups. Analysis was conducted with use of SPSS statistical software (version 10.0.7; SPSS, Chicago, Ill) with P values less than .05 considered to indicate a statistically significant difference.
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RESULTS
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Portal vein embolization was technically successful in all patients, with no difficulties experienced during the procedure (Fig 1). The mean volume of Embol-78 used was 18 mL ± 4 (range, 13–28 mL). Injection of Embol-78 through a triple lumen balloon catheter was difficult in some cases because it solidified early; however, there was no problem during injection of Embol-78 through the lumen of a 7-F sheath.
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Figure 1a. Images in a 54-year-old man with a Klatskin tumor. (a) Anteroposterior main portal venogram obtained before embolization of the right portal venous branches. (b) Anteroposterior abdominal conventional radiograph obtained after right portal vein embolization. Note radiopaque Embol-78 (arrowheads) in the right portal venous branches. (c) Anteroposterior direct portal venogram obtained after embolization shows a total occlusion (arrow) of the portal venous branches in the right lobe. (d) CT scans obtained before embolization show patent right (arrows) and left (arrowheads) portal venous branches. (e) CT scans obtained 2 weeks after portal vein embolization show complete occlusion of the right anterior and posterior portal venous branches. Note radiopaque embolic material in the right portal venous branches (arrowheads).
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Figure 1b. Images in a 54-year-old man with a Klatskin tumor. (a) Anteroposterior main portal venogram obtained before embolization of the right portal venous branches. (b) Anteroposterior abdominal conventional radiograph obtained after right portal vein embolization. Note radiopaque Embol-78 (arrowheads) in the right portal venous branches. (c) Anteroposterior direct portal venogram obtained after embolization shows a total occlusion (arrow) of the portal venous branches in the right lobe. (d) CT scans obtained before embolization show patent right (arrows) and left (arrowheads) portal venous branches. (e) CT scans obtained 2 weeks after portal vein embolization show complete occlusion of the right anterior and posterior portal venous branches. Note radiopaque embolic material in the right portal venous branches (arrowheads).
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Figure 1c. Images in a 54-year-old man with a Klatskin tumor. (a) Anteroposterior main portal venogram obtained before embolization of the right portal venous branches. (b) Anteroposterior abdominal conventional radiograph obtained after right portal vein embolization. Note radiopaque Embol-78 (arrowheads) in the right portal venous branches. (c) Anteroposterior direct portal venogram obtained after embolization shows a total occlusion (arrow) of the portal venous branches in the right lobe. (d) CT scans obtained before embolization show patent right (arrows) and left (arrowheads) portal venous branches. (e) CT scans obtained 2 weeks after portal vein embolization show complete occlusion of the right anterior and posterior portal venous branches. Note radiopaque embolic material in the right portal venous branches (arrowheads).
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Figure 1d. Images in a 54-year-old man with a Klatskin tumor. (a) Anteroposterior main portal venogram obtained before embolization of the right portal venous branches. (b) Anteroposterior abdominal conventional radiograph obtained after right portal vein embolization. Note radiopaque Embol-78 (arrowheads) in the right portal venous branches. (c) Anteroposterior direct portal venogram obtained after embolization shows a total occlusion (arrow) of the portal venous branches in the right lobe. (d) CT scans obtained before embolization show patent right (arrows) and left (arrowheads) portal venous branches. (e) CT scans obtained 2 weeks after portal vein embolization show complete occlusion of the right anterior and posterior portal venous branches. Note radiopaque embolic material in the right portal venous branches (arrowheads).
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Figure 1e. Images in a 54-year-old man with a Klatskin tumor. (a) Anteroposterior main portal venogram obtained before embolization of the right portal venous branches. (b) Anteroposterior abdominal conventional radiograph obtained after right portal vein embolization. Note radiopaque Embol-78 (arrowheads) in the right portal venous branches. (c) Anteroposterior direct portal venogram obtained after embolization shows a total occlusion (arrow) of the portal venous branches in the right lobe. (d) CT scans obtained before embolization show patent right (arrows) and left (arrowheads) portal venous branches. (e) CT scans obtained 2 weeks after portal vein embolization show complete occlusion of the right anterior and posterior portal venous branches. Note radiopaque embolic material in the right portal venous branches (arrowheads).
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There were no major complications. Most patients experienced mild to moderate abdominal pain during Embol-78 injection. However, the pain subsided spontaneously before the end of the procedure, without administration of additional analgesics in most patients. Inadvertent partial embolization of a few terminal branches of the left portal vein occurred in three patients (Fig 2). In these patients, Embol-78 was leaking around the inflated balloon and was seen with the use of fluoroscopy during injection. The inadvertent partial embolization was confirmed at postembolization main portal venography. However, there were no subsequent clinical problems. One patient had a 2.2°C elevation of body temperature 3 days after portal vein embolization, but it returned to normal within 1 week.
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Figure 2a. Images in a 57-year-old man with a Klatskin tumor. (a) Anteroposterior main portal venogram obtained before embolization of the right portal venous branches. (b) Anteroposterior left portal venogram obtained before embolization of the right portal venous branches. (c) Anteroposterior abdominal conventional radiograph obtained immediately after right portal vein embolization. Note radiopaque Embol-78 (arrowheads) in the right portal venous branches. (d) Anteroposterior main portal venogram obtained after embolization of the right portal venous branches. Note an inadvertently occluded portal venous branch (arrow) in the left lobe.
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Figure 2b. Images in a 57-year-old man with a Klatskin tumor. (a) Anteroposterior main portal venogram obtained before embolization of the right portal venous branches. (b) Anteroposterior left portal venogram obtained before embolization of the right portal venous branches. (c) Anteroposterior abdominal conventional radiograph obtained immediately after right portal vein embolization. Note radiopaque Embol-78 (arrowheads) in the right portal venous branches. (d) Anteroposterior main portal venogram obtained after embolization of the right portal venous branches. Note an inadvertently occluded portal venous branch (arrow) in the left lobe.
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Figure 2c. Images in a 57-year-old man with a Klatskin tumor. (a) Anteroposterior main portal venogram obtained before embolization of the right portal venous branches. (b) Anteroposterior left portal venogram obtained before embolization of the right portal venous branches. (c) Anteroposterior abdominal conventional radiograph obtained immediately after right portal vein embolization. Note radiopaque Embol-78 (arrowheads) in the right portal venous branches. (d) Anteroposterior main portal venogram obtained after embolization of the right portal venous branches. Note an inadvertently occluded portal venous branch (arrow) in the left lobe.
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Figure 2d. Images in a 57-year-old man with a Klatskin tumor. (a) Anteroposterior main portal venogram obtained before embolization of the right portal venous branches. (b) Anteroposterior left portal venogram obtained before embolization of the right portal venous branches. (c) Anteroposterior abdominal conventional radiograph obtained immediately after right portal vein embolization. Note radiopaque Embol-78 (arrowheads) in the right portal venous branches. (d) Anteroposterior main portal venogram obtained after embolization of the right portal venous branches. Note an inadvertently occluded portal venous branch (arrow) in the left lobe.
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The average aspartate aminotransferase level before portal vein embolization was 47 U/dL ± 27 in the hepatocellular carcinoma group and 41 U/dL ± 17 in the nonhepatocellular carcinoma group (Table). It increased to 108 U/dL ± 69 and 76 U/dL ± 37, respectively, on the 2nd day after embolization but then decreased to 55 U/dL ± 24 and 34 U/dL ± 14, respectively, the 10th day after embolization. Changes in aspartate aminotransferase levels measured before and 10 days after embolization were statistically insignificant (P = .848 in the hepatocellular carcinoma group; P = .381 in the nonhepatocellular carcinoma group). The average total serum bilirubin level prior to embolization was 0.8 mg/dL ± 0.5 (13.7 µmol/L ± 8.6) in the hepatocellular carcinoma group and 1.8 mg/dL ± 1.4 (30.8 µmol/L ± 23.9) in the nonhepatocellular carcinoma group. These levels also increased to 1.4 mg/dL ± 0.7 (23.9 µmol/L ± 12.0) and 2.3 mg/dL ± 1.5 (39.3 µmol/L ± 25.6), respectively, on the 2nd day after embolization, but they returned to baseline within 2 weeks after embolization.
One week after embolization, the lumen of the right portal vein was filled with embolizing material without portal venous flow at Doppler US in all patients. Follow-up CT images obtained 2 weeks after embolization showed atrophy of the embolized right lobe and hypertrophy of the nonembolized left lobe. After embolization, the volume of the future liver remnant increased by 110%–176% (mean, 138% ± 17) in the hepatocelluar carcinoma group and 105%–192% (mean, 146% ± 25) in the nonhepatocellular carcinoma group. The mean value of regeneration rates of the future liver remnant after embolization was 11.0 mL/d ± 3.1 in the hepatocellular carcinoma group and 16.2 mL/d ± 6.4 in the nonhepatocellular carcinoma group. The difference in the regeneration rate of the future liver remnant between each group was statistically significant (P = .005).
Mean main portal venous pressure before embolization was 16.7 mm Hg ± 3.8 in the hepatocelluar carcinoma group and 11.7 mm Hg ± 3.5 in the nonhepatocellular carcinoma group. This value increased to 20.3 mm Hg ± 3.6 and 14.6 mm Hg ± 3.6, respectively, following embolization; however, the difference in change of portal venous pressure between each group was not statistically significant (P = .263).
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DISCUSSION
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To obtain cures for advanced cases of hepatocellular and bile duct carcinoma, surgeons use an aggressive surgical approach, including extensive hepatic resection (6,7,12). However, aggressive surgery may result in the fatal complication of hepatic insufficiency. Preoperative portal vein embolization to induce hypertrophy of the nonembolized liver is a procedure that helps avoid postoperative hepatic insufficiency.
Various substances used for embolization have yielded minimally different results with different rates and degrees of hypertrophy of the nonembolized segments and associated inflammation (1–10,13). However, the optimal embolic material for portal vein embolization is still being debated. de Baere et al (2) recommend cyanoacrylate as the best substance, since it leads to fast and reliable hypertrophy, thereby minimizing the delay to definitive resection. Cyanoacrylate ensures portal vein occlusion, which persists for 4 weeks after portal vein embolization, whereas gelatin sponge particles and thrombin may allow recanalization. However, greater inflammatory reaction was noted after cyanoacrylate embolization than that after embolization with gelatin sponge particles (14). Portal vein embolization with absolute alcohol induces severe pain and damages both the liver parenchyma and peripheral bile duct. Ogasawara et al (15) reported massive hepatic necrosis after portal vein embolization with absolute ethanol. When Embol-78 was compared with absolute ethanol in an experimental study with pigs (11), results of histopathologic investigation showed lobular atrophy without necrosis, rare inflammatory cell infiltration, and obstruction of the portal venous branches. In the current study, results of histopathologic investigation of the resected right lobe also showed similar findings with preservation of the bile ducts, although some patients showed marked periportal fibrosis.
Although we did not assess the use of cyanoacrylate compared with the use of Embol-78 in the current study, portal vein embolization with use of Embol-78 has some potential advantages over embolization with cyanoacrylate. It is essential to avoid the reflux of embolizing material into the portal venous branches of the remnant liver. The embolization procedures we used involved a balloon catheter, whereas those of de Baere et al (2) did not. Cyanoacrylate polymerizes on contact with blood and is strongly adhesive to a catheter and balloon; therefore, it cannot be injected with the balloon inflated. In this situation, cyanoacrylate could reflux into contralateral portal venous branches. Also, we suspected that cyanoacrylate could not flow distally and embolize the distal small branches completely before solidifying, thereby resulting in partial recanalization or development of collateral circulation after embolization. Embol-78 is not adhesive to a balloon catheter, however, because it is in the form of an already polymerized chain that precipitates in a water environment (16). It solidifies slowly when the flow in the vessel is slow or stagnant after balloon inflation because it solidifies only when the alcohol concentration decreases below the critical value. Thus, Embol-78 can flow more distally and can completely embolize the distal small branches of the portal vein without reflux of embolizing material. In the current study, there was no evidence of recanalization of the embolized portal venous branches, although three cases of inadvertent partial embolization occurred in the future liver remnant.
There have been reports of other liquid embolic materials, including polyvinyl acetate, cellulose acetate polymer, and ethylene vinyl alcohol (17–19). However, these types of liquid embolic material have the disadvantage by being soluble only in strong organic solvents, such as 56% ethanol (polyvinyl acetate) or 100% dimethyl sulfoxide (ethylene vinyl alcohol or cellulose acetate polymer). They can also dissolve only a limited amount of water-soluble contrast media. In comparison, Embol-78 has several advantages. The partially hydrolyzed polymer Embol-78 is soluble in a less concentrated ethanol solution (44%) and miscible in larger amounts of water-soluble contrast media. The improved radiopacity (190 mg of iodine per milliliter) was thus adequate to permit monitoring of the embolization process with conventional fluoroscopy instead of digital subtraction angiography. Concern about the systemic toxicity of ethanol was also reduced because of the hydrolysis reaction.
As for the liver enzyme levels, they typically peak 1–3 days after embolization at a level less than three times that of baseline; they return to baseline 7–10 days after embolization, regardless of the substance used for embolization (1–3,5,7,14). Most of our patients also showed transient elevation of liver enzyme levels after embolization. However, none of these patients had biochemical levels that were above the baseline or normal range 10 days after embolization. Also, none of our patients except one experienced any discomfort after completion of embolization. Therefore, the biochemical data obtained in the current study indicate that Embol-78 is a relatively safe embolic agent for portal vein embolization.
Lee et al (10) reported that the regeneration rate is not as great in cirrhotic livers as that in normal livers, owing perhaps to the diminished capacity of the hepatocyte in the cirrhotic liver to respond to hepatotrophic factors. de Baere et al (2) noted less of an increase in portal venous pressure after portal vein embolization in patients with normal livers than that in patients with cirrhotic livers. As previously reported, our results showed that the liver regeneration rate was greater in the nonhepatocellular carcinoma group than that in the hepatocellular carcinoma group. However, increase of main portal venous pressure after embolization was nearly the same in both the hepatocellular carcinoma and nonhepatocellular carcinoma groups. We assume that this discrepancy is probably due to the relatively small number of patients with cirrhotic livers in the hepatocellular carcinoma group.
The relative advantages of Embol-78 have not been investigated in this study and would require a clinical trial. This study addressed safety and effectiveness of Embol-78. Portal vein embolization with Embol-78 was effective and safe in our study; however, it does have limitations. First, although lidocaine was infused through the side holes of a balloon catheter before injection of Embol-78 to prevent pain during embolization, most patients experienced mild to moderate abdominal pain during injection of Embol-78. Some of them needed additional analgesics to relieve the pain. Second, we had to wait 10–15 minutes after all branches of the right portal vein were filled with Embol-78 to allow it to solidify. We assume that the cause of the pain during injection of Embol-78 and the waiting time was ethanol concentration in Embol-78. Thus, further investigation will be needed to overcome these limitations. Finally, use of our technique for embolization of small branches, such as segment IV portal venous branches, may be impossible or laborious because of difficult catheterization and occlusion of these small branches with use of a balloon catheter.
In conclusion, although it has a few limitations, the liquid embolic agent Embol-78 seems to be safe and effective for inducing hypertrophy in nonembolized liver after portal vein embolization.
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FOOTNOTES
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Author contributions: Guarantors of integrity of entire study, K.B.S., G.Y.K.; study concepts and design, K.B.S., H.K.Y.; literature research, G.Y.K., Y.C.W.; clinical studies, K.B.S., G.Y.K., H.K.Y.; data acquisition, G.Y.K., J.H.K.; data analysis/interpretation, G.Y.K., Y.C.W.; statistical analysis, G.Y.K.; manuscript preparation, G.Y.K., Y.C.W.; manuscript definition of intellectual content, K.B.S., G.Y.K.; manuscript editing, G.Y.K., H.K.Y.; manuscript revision/review, H.K.Y., H.Y.S.; manuscript final version approval, K.B.S.
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ABSTRACT
INTRODUCTION
