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Background Patent portal vein (PV) and adequate portal inflow is essential for successful living donor liver transplantation (LDLT). In extensive portal vein thrombosis (PVT) patients, however, complete PV thrombectomy is not feasible particularly at intrapancreatic portion, and subsequently portal flow steal through preexisting sizable collaterals or rethrombosis can occur. To overcome those problems, we introduced interruption of sizable collaterals and intraoperative cine-portogram (IOP), which is useful for diagnosis and treatment of residual PVT and sizable collaterals. Methods Fourteen percent of adult LDLT (188/1399) had PVT from February 2008 to December 2012 and were subdivided into Yerdel's grades 1, 2, 3, and 4 based on preoperative imaging and operative findings. Considering the severity of PVT and presence of sizable collaterals, the managements were as follows: thrombectomy alone, additional PV plasty, PV stenting, interposition graft, or additional interruption of collaterals. Results The Yerdel's grade of PVT patients were 1 (42%), 2 (54%), 3 (3%), and 4 (1%). One hundred one (77%) patients underwent interruption of sizable collaterals. The most common management for PVT was thrombectomy alone in grades 1 and 2, thrombectomy plus PV stenting and/or ballooning in grade 3, and interposition graft in grade 4. In LDLT for PVT patients, 1-year mortality was 9%, and PV-related complication occurred in 5%. The severity of PVT made no difference in the outcome. Conclusion Multi-disciplinary approaches including surgical correction of PVT, IOP, and interruption of sizable collaterals resulted in excellent outcome, and it was not affected by the severity of PVT.

BACKGROUND The use of rituximab (Rit) to prevent antibody-mediated rejection (AMR) of ABO-incompatible (ABOi) adult living donor liver transplants (ALDLTs) has raised questions about the role of local graft infusion therapy (LGIT) and splenectomy (SPN); however, they are still regarded as essential components of the desensitization (DSZ) protocol. METHODS The DSZ protocol consisted of plasma exchange and Rit. None of the patients underwent SPN. The patients were divided into two groups. The patients in Group I (n=20) received LGIT via the hepatic artery or portal vein. The patients in Group II (n=100) did not receive LGIT. RESULTS One hundred twenty ABOi ALDLTs were performed from November 2008 to June 2012, and there was only one case of operative mortality (0.8%). There was no significant difference in the 3-year patient survival rates between patients receiving ABO-compatible and ABOi ALDLT (88.8% vs. 94.8%; P=0.11). LGIT catheter-related complications occurred in six patients (30.0%). There was no statistically significant difference in the 3-year patient survival rates between the groups (90.0% vs. 95.0%; P=0.26). One patient in Group 1 (0.8%) experienced AMR. Diffuse intrahepatic biliary stricture occurred in two patients (10.0%) in Group I and in five patients (5.0%) in Group II, although the difference was not statistically significant (P=0.11). The incidence of biliary stricture was similar in both groups (P=0.06), but the incidence of infection was significantly higher in Group I (P=0.03). CONCLUSION The DSZ protocol without LGIT and splenectomy is a safe and effective method of attaining a successful outcome of ABOi ALDLT.

Preoperative donor liver biopsy is the criterion standard to verify the quality of a liver. However, it can cause some complications, thus this study was designed to know whether selective liver biopsy is possible or not, and to find a subgroup that does not require preoperative biopsy.We reviewed preoperative images and postoperative outcome in 118 donors from September 2013 to January 2014. Visual grading of steatosis on plain computed tomography (CT) was performed and compared steatosis on preoperative liver biopsy was done within 7 days from the CT scan.Visual grades of plain CT were 1 (n = 50, 42.4%), 2 (n = 47, 39.8%), 3 (n = 13, 11.0%), 4 (n = 7, 5.9%), and 1 (n = 1, 0.8%). Macrovesicular steatosis on liver biopsy according to visual grades were 1 (0.67 ± 1.3%), 2 (1.67 ± 1.8%), 3 (6.23 ± 6.4%), 4 (14.7 ± 16.6), and 5 (30%). Right liver grafts including right lobe, modified right lobe, and extended right lobe were procured in 106 (89.9%) donors, and 16% (17/106) of the donors were visual grades 3, 4, and 5. Eleven donors (64.7%) were accepted for right liver donation after liver biopsy, whereas 6 (35.3%) donors were deemed possible to donate right liver after weight reduction and reevaluation of steatosis. Transient hepatic dysfunction after right hepatectomy was significantly increased according to the increment of visual grade.Preoperative liver biopsy may not be necessary in visual grade 1 or 2 donors, but should be performed for grade 3 and 4 donors based on recipient's urgency so as to decide whether to proceed with right hepatectomy or not.

Right lobe living-donor liver transplantation (LDLT) is often not attempted in donors with anomalous portal venous branching (APVB). The authors describe their experience with portal vein (PV) reconstruction in 17 cases of APVB in right lobe LDLT. From July 1997 to December 2001, 214 right liver LDLT were performed at the Asan Medical Center. Seventeen of the donors had APVB and successfully underwent right lobectomy. The APVB were type II (trifurcation) in nine cases, type III (independent posterior segmental branching from main PV trunk) in seven, and unclassified in one. All 17 donors and recipients are alive, with good liver function. In type II APVB, the donor PV branches were obtained with separate openings that were joined as a common orifice at the back table in two, with a discoid-patch single opening in four, and with one common opening in three. In type III APVB, the donor PV were divided with two openings in four and with a discoid-patch single opening in three. The discoid-patch defect in the remnant PV was repaired with a vein patchplasty in two donors and resected with end-to-end anastomosis in five. However, one donor developed portal vein thrombosis (PVT) that was managed successfully by re-exploration and insertion of a metallic vascular stent. Of the four type III APVB obtained with two separate PV openings, the first two liver grafts were each reconstructed as double PV anastomoses. One of them required re-exploration because of PVT. In the two succeeding cases, a Y-graft interposition technique using a cryopreserved cadaveric iliac vein or the recipient's own portal confluence was successfully applied. To minimize the risk of PVT in donors with APVB, discoid-patch excision followed by repair with vein patchplasty or segmental resection should be avoided. Individual division of the PV branches creating two separate openings instead is recommended. To decrease the recipient's risk of PVT, interposition Y-graft venous reconstruction at the back table is superior to double PV anastomoses.

Background. Right liver grafts without middle hepatic vein (MHV) drainage reconstruction resulted in severe congestion of the anterior segment (AS) in our early experience of adult-to-adult living donor liver transplantation (LDLT). However, a detailed strategy for preventing such congestion or the necessity of MHV reconstruction has not been discussed in LDLT using a right lobe graft. Methods. From July 1997 to February 1998, two of five right lobe grafts without MHV drainage reconstruction were complicated with severe congestion of the AS. Thereafter, 42 adult recipients who received right liver grafts with sizable MHV tributaries underwent the reconstruction of MHV drainage. All sizable (>5 mm in diameter) MHV tributaries were preserved during donor hepatectomy and were reconstructed with the recipient's autogenous interposition vein grafts at the bench surgery. The reconstructed vein grafts of this modified right lobe graft were anastomosed to the stump of the MHV and/or left hepatic vein of the recipient after graft revascularization. Results. Serial Doppler ultrasonography, which was regularly checked until 30 days posttransplant, revealed the patent interposition vein graft in 38 of 42 recipients (patency rate 90.5%). In these 38 recipients, no evidence of congestion in the AS was recognized on enhanced computed tomography, while providing enough functioning liver mass comparable to an extended right lobe graft. Also, congestion-related graft injury, such as an infarct of the AS, was not observed in these recipients. Conclusions. Our early experience indicated the necessity of MHV drainage reconstruction in right lobe grafts, which do not have MHV trunk in certain instances. However, preoperatively, it is difficult to predict the degree of AS congestion of the right liver graft without MHV drainage reconstruction. We suggest aggressive reconstruction of MHV drainage tributaries of the AS, under the circumstances that sizable MHV tributaries are encountered, to prevent possible congestion-related complications.

The disparity between patients awaiting transplantation and available organs has widened, and resultant organ shortage became a world crisis. The transplantation community has made considerable progress in national organ donation system in Korea, and significant growth in the number of deceased donors has been witnessed.After introduction of the Organ Transplant Act, which was enacted in 2000, transparency was established in organ allocation system in Korea. However, the number of deceased donor dwindled significantly from 162 in 1999 to 36 in 2002. To improve deceased donation, several strategies were pursued, and finally new national organ donation system was established through the amendment of the Organ Transplant Act.Organ incentive system, which was introduced in 2003, failed to increase the number of deceased donors (68 in 2003, 86 in 2004, and 91 in 2005). Monetary incentive to the bereaved family was introduced in 2006 and slightly increased the number of deceased donor (141 in 2006). However, this effect was not long-lasting (148 in 2007). After enforcement of the new Organ Transplant Act, which included nationwide independent organ procurement organization and mandatory report of potential brain death, the number of deceased donors significantly increased, reaching 368 in 2011. The growth continued and the number of deceased donors reached 409 (8.03 pmp) in 2012.There has been a significant growth in the number of deceased donors in Korea since the appropriate deceased organ donation system was launched. A comprehensive national program is required to improve deceased donation and achieve self-sufficiency.

BACKGROUND An exchange living donor program for liver transplantation, similar to the exchange living donor kidney program, was proposed to avoid ABO-incompatible adult living donor liver transplantation (LDLT). The objective of this study was to present updated changes in exchange adult LDLT program at our institution. METHODS Between January 2003 and December 2011, approximately 2,182 adult LDLT cases were included in this study. During this period, 26 paired-exchange donor LDLT cases were performed (1.2%). RESULTS Of the 26 paired-exchange donor LDLT cases, 22 pairs were matched due to ABO-incompatibility, and 4 pairs were matched because of cascade allocation of unrelated donors or relatively small graft volume to the recipients. A total of 28 living donors were included in the 26 paired-exchange donor LDLT cases because of inclusion of two dual-graft transplants. Elective surgery was performed in 22 cases, and urgent operation was performed in 4 cases. The overall 1-year and 5-year patient and graft survivals were both 96.2% and 90.1%, respectively. CONCLUSIONS Our experience suggests that the paired-exchange donor program for adult LDLT seems to be a feasible modality to overcome donor ABO incompatibility. Reasonably acceptable indications for donor exchange LDLT will be proposed in near future.

For adult patients with end-stage liver disease, living-donor liver transplantation (LDLT) of right-lobe grafts with or without the middle hepatic vein (MHV) has been increasingly used in recent years. We investigated the role of the MHV in donor remnant liver regeneration after right-lobe LDLT, which has not been described in previous studies. A total of eight living donors were included in this study of right-lobe LDLT. Four donors underwent right lobectomy (without MHV), and the remaining four underwent extended right lobectomy (with MHV). Regeneration of the donor remnant liver was assessed by volumetric computed tomography studies before and 90 days after LDLT. Comparison between the right-lobe and extended right-lobe donors did not show a clear-cut difference in the net increase of remnant liver volume at 3 months. However, the mean volume increase of the medial segment at the 90th postoperative day was 7% in the extended right-lobe donors and 61% in the right-lobe donors, showing a lower value in the remnant livers without MHV. The MHV plays a specific role in remnant liver regeneration of right-lobe living donors. We expect that this knowledge will contribute to securing a margin of safety in right-lobe LDLT.

Background Left liver graft from a small donor will not meet the metabolic demands of a larger adult recipient. One solution to this problem is to use a right liver graft without a middle hepatic vein (MHV). However, the need for drainage from the MHV tributaries has not yet been described. Methods Five right liver grafts without a MHV were transplanted in patients including two hepatitis B virus-cirrhosis, two fulminant hepatic failure and one secondary biliary cirrhosis. The graft weight ranged from 650 to 1,000 g, corresponding to 48 to 83% of the standard liver volume of the recipients. Results Two of five recipients were complicated with severe congestion of the right median sector immediately after reperfusion, followed by prolonged massive ascites and severe liver dysfunction. One of the patients died of sepsis with progressive hepatic dysfunction 20 days after the operation. Conclusions Preservation and reconstruction of the MHV tributaries is recommended to prevent congestion of the right liver graft without MHV.

Serologic evidence of resolved hepatitis B virus (HBV) infection (HBV surface antigen negative, anti-HBV core antibody [HBc] positive) in a liver donor can be regarded as an occult infection with episomal HBV in the liver. The purpose of this study was to evaluate the safety of anti-HBc-positive living donors. Between March 2001 and January 2002, 127 donors underwent hepatectomy for living-donor liver transplantation at Asan Medical Center. They were classified as members of an anti-HBc-positive group (n=50) or an anti-HBc-negative group (n=77). The two groups were subdivided into right lobectomy (n=86) and left lobectomy (n=34) groups to compare operative risk. Perioperative clinical profiles were compared by anti-HBc status and extent of donor hepatectomy. There were no statistical differences of preoperative liver function and liver steatosis between the anti-HBc-positive and anti-HBc-negative groups. Operation time and blood loss did not show any differences between the hepatectomy-matched anti-HBc-positive and anti-HBc-negative groups. Postoperative recovery of liver function, incidence of complication, and regeneration rate of the remnant liver after right lobectomy also did not show significant differences. The anti-HBc-positive group did not exhibit any adverse preoperative, intraoperative, or postoperative outcomes compared with the anti-HBc-negative group. This indicates that anti-HBc-positive donors can be assessed to have the same degree of risk for donor operation as anti-HBc-negative donors.

Right liver grafts without middle hepatic vein (MHV) drainage reconstruction resulted in severe congestion of the anterior segment (AS) in our early experience of adult-to-adult living donor liver transplantation (LDLT). However, a detailed strategy for preventing such congestion or the necessity of MHV reconstruction has not been discussed in LDLT using a right lobe graft.From July 1997 to February 1998, two of five right lobe grafts without MHV drainage reconstruction were complicated with severe congestion of the AS. Thereafter, 42 adult recipients who received right liver grafts with sizable MHV tributaries underwent the reconstruction of MHV drainage. All sizable (5 mm in diameter) MHV tributaries were preserved during donor hepatectomy and were reconstructed with the recipient's autogenous interposition vein grafts at the bench surgery. The reconstructed vein grafts of this modified right lobe graft were anastomosed to the stump of the MHV and/or left hepatic vein of the recipient after graft revascularization.Serial Doppler ultrasonography, which was regularly checked until 30 days posttransplant, revealed the patent interposition vein graft in 38 of 42 recipients (patency rate 90.5%). In these 38 recipients, no evidence of congestion in the AS was recognized on enhanced computed tomography, while providing enough functioning liver mass comparable to an extended right lobe graft. Also, congestion-related graft injury, such as an infarct of the AS, was not observed in these recipients.Our early experience indicated the necessity of MHV drainage reconstruction in right lobe grafts, which do not have MHV trunk in certain instances. However, preoperatively, it is difficult to predict the degree of AS congestion of the right liver graft without MHV drainage reconstruction. We suggest aggressive reconstruction of MHV drainage tributaries of the AS, under the circumstances that sizable MHV tributaries are encountered, to prevent possible congestion-related complications.