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Successful vascular adult thymus transplant has been reported in different animal models but not in rabbits. These animal models are slightly larger than the murine and substantially smaller than the porcine. We describe in rabbits a supermicrosurgical technique for vascular neonatal thymus transplant and provide histologic evidence of tissue viability.Newborn (New Zealand, n = 12, 6 female) and adult (New Zealand, n = 12, 6 female) rabbits were used as donors and recipients, respectively. Whole thymuses were extracted from donors and grafted into recipients. Immediate direct vascularization was accomplished by anastomosis to the right common carotid artery and the right external vena cava. At day 14, graft sites were surgically explored, and grafted thymuses were explanted for histologic evaluation. All recipients were followed over 2 weeks for clinical signs of graft-vs-host reaction.The vascular pedicles of the thymus grafts ranged 0.5 to 0.8 mm in vessel diameter. From the 12 transplants, 3 recipients (3/12; 25%) died during the surgical procedure because of blood loss after clamp release. On histology, from the 9 (9/12; 75%) successful at revascularization, none (0/9; 0%) had signs of acute rejection or necrosis, and all (9/9; 100%) evidenced normal cytoarchitecture. No clinical signs of graft-vs-host reaction were evidenced during follow-up.Vascular neonatal thymus transplant in rabbits is surgically feasible. This technique will enable a novel approach for studying the biology of the thymus.

Background In this study, we compared the outcomes of three different surgical microscope–assisted end-to-side anastomosis techniques between the dominant and accessory renal arteries during living donor kidney transplant. Methods The demographics, serum creatinine levels, warm and cold ischemia times, rate of complications, and incidence of delayed graft function of 135 kidney recipients were analyzed according to the type of arterial anastomosis. Group A (n = 98) had one dominant renal artery (DRA) with one end-to-side anastomosis to the external iliac artery (EIA) using a surgical microscope. Group B (n = 17) had one DRA plus one accessory renal artery (ARA) with two separate end-to-side anastomoses to the EIA using a surgical microscope. Group C (n = 20) had one DRA with end-to-side anastomosis to the EIA and one ARA with an ex vivo on-bench end-to-side anastomosis to the DRA using a surgical microscope. Results Compared with groups A and B, the cold ischemia time and the rate of delayed graft function were significantly higher in group C (P ≤ .001). At 6 months after transplant, group B demonstrated a higher creatinine value (2.40 ± 3.41 mg/dL) than group A and group B (P = .032). Also, the decrease in creatinine at postoperative month 6 was limited in group B as compared with groups A and C. Conclusions An end-to-side anastomosis between ARA (group B) and DRA (group A) of the kidney graft using a surgical microscope on the bench ex vivo results in superior outcomes. Single arterial anastomosis techniques are associated with a better function in a 6-month follow-up than two separate arterial anastomoses.

Although a short and nonredundant anastomosis is most often performed in liver transplantation, there is no strong evidence in the literature about the ideal arterial reconstruction. We describe here the "long-artery" technique that enables a wide side-to-end anastomosis and preserves arterial length.We present the results between 2011 and 2019 of the "long-artery" technique performed in our center. Patients with a split liver transplantation or aortohepatic conduits were not included. This technique uses the whole arterial axis of the graft. A side-to-end anastomosis is performed between the common and/or proper hepatic artery of the recipient, and the celiac trunk with an aortic patch of the graft, while the gastroduodenal artery of the recipient is preserved. An omental flap is positioned under the graft artery to prevent kinking.Eight hundred thirty-two transplant patients were included in the analysis. Early hepatic artery thrombosis was diagnosed in 22 (2.6%) patients and occurred within the first 10 days after the procedure. A thrombectomy was performed in 7 patients, which was successful in 4 patients, and 18 patients were retransplanted. Seven patients (0.8%) developed a late hepatic artery thrombosis, including 2 patients who were retransplanted.The "long-artery" technique is a safe and efficient technique for arterial reconstruction in liver transplantation and does not seem to increase the rate of early hepatic artery thrombosis.

Background Urological complications after renal transplantation (RT), including urine leaks, remain the most common type of surgical complications in the early post-transplant period. In this study we evaluated 324 consecutive RTs recipients in whom Haberal’s corner-saving anastomosis technique was used for ureteroneocystostomy. Material and Methods Since January 2018, 461 RTs were performed at our center. Haberal’s corner-saving anastomosis technique was used in 324 of these 461 RTs and the effectiveness of the technique was analyzed retrospectively. There were 115 female patients and 209 male patients, with a mean age of 42.1 ± 13.9 years. The most common etiology resulting in RT was hypertension among the recipients. Results We observed 8 (2.4%) ureteral complications in 7 recipients as follows: ureteral stenosis in 2 recipients (0.6%), anastomotic leaks in 1 (0.3%), concomitant leak-stenosis in 1 (0.3%), and vesicoureteral reflux in 3 (0.9%). Six complications were treated with interventional radiological techniques and 2 were treated surgically. There was no graft and patient loss in the event of urological complications. Conclusion Because of the low complication rate, we believe that Haberal’s corner-saving ureteral anastomosis technique is a safe method for performing a ureteroneocystostomy.

Hepatic artery (HA) complications after liver transplant (LT) can lead to biliary complications, graft failure, and mortality. Although microsurgery has been established to improve anastomotic outcomes, it prolongs surgical time and has not reached widespread adoption at all transplant centers. We investigated the incidences of arterial, biliary complications and outcomes after using microsurgery to anastomose HA during LT. Retrospective cohort of consecutive LT performed from 2006 to 2018 was reviewed for operative details and postoperative outcomes. Cox-regression models were used to investigate the relationship between variables and outcomes. Eighty (62.5%) LTs (Group 1) were performed without and compared with 48 (Group 2) with microsurgical anastomosis of HA. Both groups were comparable in terms of arterial and biliary anastomoses performed. Incidence of early HA thrombosis was similar (6.2% vs 2.1%, P = .28). Group 2 had lower incidence of short- and long-term arterial complications, especially amongst living donor liver transplantations (LDLT) (5.3% vs 35.0%, P = .022). On multivariate analysis, microsurgery was associated with lower risk (hazard ratio [HR] 0.09, 95% confidence interval [CI] 0.01-0.71) of, and LDLT had higher risk (HR 4.23, 95% CI 1.46-12.27) of arterial complications. Biliary complications were associated with LDLT (HR 3.91, 95% CI 1.30-11.71) and dual biliary anastomoses (HR 5.26, 95% CI 1.15-24.08) but not with occurrence of HA complications. Worse patient survival was associated with the occurrence of any HA complication (HR 4.11, 95% CI 1.78-9.48). Hepatic arterial complications can be reduced using microsurgical techniques for the anastomosis, resulting in improved patient survival outcomes after liver transplantation.

Background Hepatic vein reconstruction is very important in living donor liver transplantation to prevent outflow obstruction and maintain the graft function. In right liver grafts, reconstruction of the tributary of the middle hepatic vein (MHV) or inferior hepatic vein (IHV) is mandatory, and several options are recommended. Recently, it has been reported that a single, wide orifice is an important perquisite for adequate outflow in liver transplantation. This can be achieved by various venoplasty techniques in back table procedures using the recipient’s saphenous vein, a cryopreserved vascular graft, or a synthetic vascular graft. Methods Due to the insufficiency of an actual graft, we used a simple back table technique with the polyethylene terephthalate Y-graft in 3 cases of right liver grafting between October 2015 and September 2019 in Gil Medical Center. We used both arms of the Y-graft for anastomosis of the 2 largest branches of both tributaries. The main trunk of the Y-graft was then joined to the right hepatic vein (RHV). We analyzed these patients’ outcomes retrospectively and the study was approved by institutional review board in Gachon University Gil Medical Center. This study strictly complies with the Helsinki Congress and the Istanbul Declaration regarding donor source and informed consent was obtained from all patients. Results All 3 patients had good tributary patency and allograft function at discharge. The patency of the graft was maintained over a period ranging from 2 months to 2 years, without any anticoagulant administration. Regardless of the tributary patency, all patients survived with good outflow of the grafts. Conclusions Although we had little prior experience in synthetic venous grafts, these cases indicate some interesting findings, with a simple and intuitive procedure. We believe our technique is a practical method for manipulating various venous tributaries in a right liver graft.

Purpose The study aimed to evaluate the feasibility and effectiveness of the endoscopic treatment in transplanted patients with neurogenic bladder who complained of symptomatic vesicoureteral reflux (VUR). Material and Methods Fifteen patients with VUR who were previously diagnosed with a neurogenic bladder were included in the study. The Lich-Gregoire technique was used for ureterovesical anastomosis during transplantation, and a double J stent was inserted routinely in the ureter to protect the anastomosis. The sting operation was performed under general anesthesia in the lithotomy position. A 4.8 Fr double J stent (Boston Scientific, Boston, MA) was inserted to prevent the risk of ureteral obstruction. Successful treatment was defined as absent acute glomerulopyelonephritis (AGPN) during follow-up and as absent VUR on radiological evaluation. Results Clinical success was achieved in 6 of 10 patients (60%) who presented with recurrent febrile urinary tract infection (UTI) and in 4 of 6 (66%) patients who presented with gradually graft function deterioration. In 3 patients, the ureteral neo-orifice could not be localized during the operation owing to severe trabeculation of the bladder wall. The other 2 patients with a previous history of augmented bladder procedures had a hypotension attack during bladder filling; hence, the operation was stopped to prevent further complications. Two patients, whose clinical symptoms did not resolve after the sting procedure, accepted open ureteral reimplantation surgery. Conclusion Endoscopic management of the VUR in the transplant patients with neurogenic bladder function is safe and effective in at least half of the patients in a mid-term follow-up period.

The classic piggyback technique uses the union of the 3 hepatic veins to perform the cavo-caval anastomosis. However, due to the lateral localization of the right hepatic vein, the partial clamping of the vena cava in this technique significantly reduces the venous return to the right atrium. To avoid this, we adopted in 2015 a modified piggyback technique, in which we use the common trunk of the middle and left hepatic veins and also perform a lateral incision toward the right in the anterior wall of the vena cava in order to widen the final ostium of the cavo-caval anastomosis. The aim of the study was to analyze the incidence of hepatic venous outflow obstruction between those 2 techniques.Retrospective study of liver transplant recipients undergoing venography for suspected hepatic venous outflow obstruction from January 2009 to June 2021. Patients undergoing transplantation with living donors or split grafts and pediatric cases were excluded from the study.From January 2009 to December 2014 and from January 2015 to June 2021, 587 (group 1) and 730 (group 2) deceased-donor liver transplants were performed with the classic and the modified piggyback techniques, respectively. The incidence of cases with suspected hepatic venous outflow obstruction in groups 1 and 2 were 1.87% (n = 11) and 0.95% (n = 7), respectively (P = 0,15). The number of confirmed patients with outflow blockage that required endovascular treatment during venography in groups 1 and 2 were 4 (0.68%) and 5 (0.68%), respectively (P = 0,31).This modified piggyback technique did not increase the incidence of hepatic venous outflow obstruction at our service.

Introduction Liver transplant remains a surgical challenge in cases of portal vein thrombosis. Ten percent of patients listed for liver transplant have this diagnosis preoperatively. Although several techniques of portal revascularization are available, sometimes the best result is not achieved, depending on the extent of thrombosis. Objective The aim of this article is to report our experience in 2 particular cases of liver transplant with portal vein thrombosis. Material and Methods We present the cases of 2 patients with partial portal thrombosis that extended to the porto-spleno-mesenteric system. The first case is a 36-year-old woman with recurrence of autoimmune liver disease requiring a second graft; the second case concerns a 64-year-old man with alcoholic liver cirrhosis. Results Both patients had a splenorenal shunt. A portal bypass with a Y venous graft was performed using the cavoiliac veins of the donor. The anastomosis was performed to the superior mesenteric and left renal veins. Discussion and Conclusions These clinical cases demonstrate that portal vein thrombosis is not an absolute contraindication for transplantation and that surgical alternatives exist in cases of grade III portal vein thrombosis.

Aims Our aim was to review the rate of biliary duct stones (BDS) after liver transplantation (LT), risk factors, and treatments, and to identify predictive factors for their onset. Methods LTs performed in our center from 2004 to 2014 were studied. Risk factors for the onset of BDS were identified using univariable Cox’s proportional hazards models. Results Three hundred and sixty-four grafts with 317 duct-to-duct end-to-end biliary anastomosis on a T-tube and 47 hepaticojejunal anastomosis (HJ) were analyzed. BDS were identified in 13 of 364 (3.5%) grafts, including 10 duct-to-duct end-to-end biliary anastomosis on a T-tube grafts (3.2%) and 3 HJ grafts (6.4%). Predictive factors for BDS were biliary strictures (hazard ratio [HR] 9.94; 95% confidence interval [95% CI] 3.25–30.4), bilirubin (HR 1.04; 95% CI 1.01–1.06, for 1 unit increase), Model for End-Stage Liver Disease score (HR 1.07; 95% CI 1.01–1.14, for 1 unit increase), surgery time (HR 1.04; 95% CI 1.01–1.08, for 10-minute increase), hepatocellular disease (HR 8.3; 95% CI 1.09–64.0), hepatic artery thrombosis (HR 6.71; 95% CI 1.47–30.6), and retransplantation (HR 3.69; 95% CI 1.02–13.43). Among 51 grafts (14%) with biliary strictures, female sex was identified as a risk factor for BDS (HR 5.19; 95% CI 1.29–20.98). Multimodality treatment of BDS was often successful but open surgery was still needed in 23% of them. One-, 5-, and 10-year graft survival was not influenced by the onset of BDS. Conclusion Main predictive factor for BDS in liver grafts is biliary stricture. Recipient’s age and body mass index failed to show any statistical importance. In grafts with biliary strictures, female sex is the main risk factor for BDS. In the absence of biliary strictures, hepatic artery thrombosis lead to an increase in the risk of BDS. Multimodality treatment of BDS is often successful. BDS do not influence outcome.

The issue of performing an anastomosis of the anterior sector veins to the vena cava in living donor liver transplantation is still controversial. We aimed to research whether there was any difference in terms of complications, rejections, and graft survival between patients with and without anterior sector venous drainage to the vena cava.Patients were retrospectively investigated for demographic data and ratio of graft needed to available graft weight. Donors had volumetric calculations and middle hepatic vein anterior sector drainage documented in detail.Seventy-three donors with middle hepatic vein drainage were included. Thirty-five had anterior sector venous drainage performed and 38 patients did not have drainage procedures performed. The incidence of general complications was higher in the group without anterior sector drainage (78.3% and P = .002). Biloma linked to bile leaks were observed in 8 patients without drainage (72.8%) and 3 patients with drainage (27.2%). Late acute rejection occurring during follow up after transplantation was identified in 28 patients (11.6%). Of these, 1 (14.3%) had anterior sector drainage and 6 (85.7%) were in the patient group without drainage (P = .067).As a result of this study, for patients with grafts at the volume limit (graft weight to receiver weight ratio 0.8) and with congestion observed in the anterior sector after liver implantation and for patients with outflow problems identified on Doppler ultrasonography, anterior sector veins5 mm should definitely be drained into the vena cava. Hence, both complication and rejection rates will reduce, and we can lengthen the graft, and thus patient, survival.

Objective This study was performed to investigate the safety and efficiency of the renal vein “beltization” technique for laparoscopic orthotopic kidney transplantation (LOKT) in a pig model. Material and Methods Kidney autotransplants were conducted, in which the renal vein beltization technique was employed, in 12 domestic pigs. In the operation, the right kidney was autotransplanted to the left kidney vessel trunks. Data of the operative time, venous anastomotic time, vein stenosis, blood loss, kidney graft function, and survival for the pigs were recorded. One week later, the transplanted autograft was removed for observation from the surviving animals while under anesthesia. A silicon tube cage was used to induce hypothermia during laparoscopic operation. Results All 12 LOKTs were finished. The mean warm ischemia time was 5.22 ± 1.33 minutes, and the mean cold ischemia time was 263.44 ± 50.82 minutes. The mean transplant operative time was 305.67 ± 30.88 minutes. The venous and arterial anastomotic times were 68.42 ± 8.51 minutes and 40.92 ± 9.83 minutes, respectively. After revascularization, an immediate and viable blood supply was seen in 7 grafts based on the appearance of a bright red color. Four pigs urinated immediately after the operation, and 3 produced urine on the next day; 4 pigs received life-supporting renal autografts for 7 days. Autopsy results showed 3 artery stenoses and 3 vein stenosis. Thrombi were found in all of these strictured vessels. The median survival time of the pigs was 5.55 days. Conclusions The renal vein beltization technique may facilitate laparoscopic pig venous anastomotic procedures and ensures the quality of reconstruction. It is helpful for venous anastomoses in LOKT.

Cholangitis is a major complication following transplantation. We report a living donor liver transplant (LDLT) patient with cholangitis due to multiple stones in the intrahepatic bile duct during hepaticojejunostomy anastomosis, who was successfully treated with the rendezvous technique using double balloon endoscope. A 64-year-old woman underwent LDLT with right lobe graft and hepaticojejunostomy for Wilson disease. There was bile leakage with biliary peritonitis, which was treated conservatively after transplant. Two years after surgery, she developed reiterated cholangitis due to stenosis of hepaticojejunostomy anastomosis and multiple stones in the intrahepatic bile ducts. Percutaneous transhepatic biliary drainage was performed. The size of the drainage tube was increased, and the anastomotic area was dilated in a stepwise manner using a balloon catheter. The stones were crushed and lithotomy was performed using electronic hydraulic lithotripsy through cholangioscopy. Finally, lithotomy was performed for the remaining stones through endoscopic retrograde cholangiography with the rendezvous technique using the double balloon endoscope. Rendezvous approach with percutaneous transhepatic biliary drainage and double balloon endoscopic retrograde cholangiography was an effective treatment for the multiple intrahepatic stones in hepaticojejunostomy following LDLT with right lobe graft.

It is true that multiple arterial reconstructions are sometimes required in living donor liver transplant (LDLT). However, the best procedure is still controversial regarding arterial reconstruction in liver grafts with multiple arteries.A total of 93 patients, 55 right lobe grafts and 38 left lobe grafts, who underwent LDLT at our university from 2003 to 2017 were enrolled for this study. Regarding arterial reconstruction in grafts with multiple hepatic arteries, the dominant artery was reconstructed first. Subsequently, when both the pulsating arterial flow from the remaining artery stumps and the intra-graft arterial flow by Doppler ultrasonography were confirmed, the remaining arteries were not reconstructed. The patients were divided into the following 3 groups: (1) single artery/single reconstruction (n = 81), (2) selective arterial reconstruction of multiple arterial grafts (n = 7), and (3) multiple arterial reconstructions (n = 5).A total of 12.9% (12/93; right lobe: 2/55; left lobe 10/38) of grafts had multiple arteries. The incidence of multiple arteries was significantly higher in the left lobe grafts (P = .0029). The arterial diameters (SD) of multiple arterial grafts were narrower (2.43 [0.84] mm) than single arterial grafts (3.70 [1.30] mm) (P = .0135). Extra-anatomic arterial reconstruction were frequently required in multiple arterial reconstructions (group 1 and 2 vs 3) (P = .0007). The strategy of selective arterial reconstruction with the above criteria did not negatively affect the rates of biliary complications or the overall patient survival (P = .52).It can be argued that selective arterial reconstructions demonstrated acceptable outcomes in LDLT, provided that the above criteria were satisfied.

Background The reconstruction of the hepatic artery (HA) is the most complex step in living-donor liver transplantation (LDLT) owing to the artery's smaller diameter and the increased risk for HA-related complications. In this study, we presented our HA anastomosis technique for LDLT, which employed interrupted sutures using magnifying loupes. Materials and Methods Since January 2019, we retrospectively analyzed 179 LDLTs that were performed at our center. HA anastomosis was performed under a loupes magnifier (2.5 or 4.5 × ) by the same surgeon. Results There were 65 female and 114 male recipients with a mean age of 41.6 ± 21.6 years. Of the recipients, 34 were children. HA thrombosis (HAT) was seen in 3 recipients (1.67%; 1 child and 2 adults) in this series. HAT occurred on the third, sixth, and seventh days after LDLT. HAT was successfully treated with interventional radiologic technique. All recipients are still alive with a patent HA. Conclusion The use of magnifying surgical loupes and interrupted sutures to perform HA reconstruction is safe, feasible, and yields a low rate of HAT. Also, endovascular treatment can be used safely for treatment of HAT within the first week after LDLT with a high success rate and is not associated with major complications.

Background Renal transplantation is an effective treatment for end-stage renal disease, which involves pathophysiologic processes such as ischemia-reperfusion injury and immune rejection. The degree of ischemia-reperfusion injury is closely related to the functional state of the transplanted kidney. At present, the allogeneic kidney transplantation model has been widely used in related research. The traditional kidney transplantation model has the disadvantages of complicated vascular anastomosis, difficulty in ureteral reconstruction. The aim of this study was to establish a rat autologous orthotopic kidney transplantation model based on non-anastomotic technique. Methods Inbred Wistar rats weighing 260 to 280 g were selected. The rats were anesthetized by intraperitoneal injections of 40 mg/kg body weight pentobarbital sodium. We exposed and freed the left kidney after laparotomy and separated the left renal artery and left renal vein, abdominal aorta, and posterior vena cava. A purse-string suture with a diameter of 1 to 2 mm was made through the tunica media of the abdominal aorta. A puncture was made through the center of the purse-string suture. The in-dwelling needle was placed in the renal artery along the blood flow direction, and was infused with constant flow of 4°C heparinized lactated ringer's solution until the kidney became pale yellow. The renal vein was ligated and the renal artery was clamped. The in-dwelling needle was removed, purse-string suture was ligated, and the kidney was stored in a self-made autologous kidney transplant cold storage bag for 4 hours. We then opened the vein and artery, removed the cold storage bag, and rewarmed with 37°C normal saline. The abdomen was then closed layer by layer. Results Fifty-two orthotopic renal transplantations were performed, which included pre-experimental (40 operations) and experimental stages (12 operations). The success rates of the 2 stages were 75% and 91.7%, respectively. The main causes of failure were intraoperative hemorrhagic shock and postoperative infection. The operation time of orthotopic renal transplantation was 360 ± 30 minutes, including 30 ± 10 minutes for dissociation and management of kidney and blood vessels, 1 ± 0.5 minutes for warm ischemia and 240 ± 10 minutes for cold storage. Rats were sacrificed at 1 day and 7 day respectively. The rats were in good condition after operation. They could eat and drink freely. At 24 hours and 1 week after transplantation, the kidney's blood supply was good, the intestine was light or showed no adhesions, and the abdominal cavity had no ascites or peculiar smell. Hematoxylin & eosin (H&E) staining showed that there were no obvious pathologic changes in the sham group. The orthotopic kidney transplantation 1-day group showed pathologic changes of ischemia-reperfusion, such as swelling, necrosis, shedding, and cast formation of renal tubular cells. The orthotopic kidney transplantation 7-day group recovered well, with mild dilation of the renal capsule and mild dilatation of the renal tubules. Conclusion The new model of autologous kidney transplantation is simple to use, does not require vascular anastomosis and ureteral reconstruction, and has a high success rate.

BACKGROUND Although liver transplantation is widely accepted as the therapeutic strategy for end-stage liver failure, complication of hepatic venous outflow obstruction remains lethal. Currently, ensuring a single wide orifice in both the graft and recipient inferior vena cava has been proposed to avoid hepatic venous outflow obstruction with no theoretical concept. METHODS We herein report a standardization technique for the reconstruction of the hepatic vein based on the causal analysis. RESULTS During the put-in process, the graft must be positioned in contact with the recipient diaphragm and slightly pushed to the cranial direction to simulate the state after abdominal closure. Because there is no extra space between the graft and diaphragm, the graft could not rotate about the anastomotic site of the inferior vena cava toward the diaphragm after abdominal closure as the intestinal pressure increases, and accordingly hepatic venous outflow obstruction does not develop. CONCLUSIONS With this concept, all transplant surgeons can successfully and easily perform hepatic vein reconstruction without total clamping of the inferior vena cava and without outflow block.

In the present retrospective study, we analyzed the outcomes of patients transplanted with grafts with multiple renal arteries (MRAs).In total, 89 patients were transplanted with renal grafts with MRAs from 2003 to 2018. Demographic characteristics; type of donor; warm and cold ischemia times; arterial anastomosis technique; complications; graft function at first month, first year, and last outpatient clinic visit; and patient and graft survival were all retrospectively evaluated.The mean age of the patients was 40.4 ± 13.3 years. Fifty-six patients (62.9%) were male. In total, 42 patients (47.2%) received renal grafts from living related donors. In group A (n = 24; 27%), anastomosis was performed separately to the recipient external or internal iliac arteries; in group B (n = 38; 42.7%), the secondary artery was anastomosed to the main artery in a side-to-side fashion to form a single common orifice; in group C (n = 27; 30.3%), secondary arteries were anastomosed to the main renal artery in an end-to-side fashion. Creatinine clearance at the first month was significantly lower for deceased-donor grafts compared to living-donor renal grafts (P .05). Creatinine clearance in the first postoperative month was significantly lower in group A and creatinine clearance in the first year was significantly lower in group C (P .05). The best survival was found for anastomosis to the internal iliac artery (P .05).MRAs can be safely used and the reconstruction technique does not matter if the graft kidney's arterial supply is preserved and the internal iliac artery is chosen for anastomosis.

Background Biliary complications in liver transplantation (LT) can cause significant morbidity or even lead to a potential graft loss and patient mortality. Oftentimes biliary internal stents (ISs) are used at the time of LT to lower the risk for or prevent these biliary complications; however, their efficacy and outcomes remain controversial. Methods A retrospective cohort study was conducted on all of the adult patients who underwent a deceased-donor LT (DDLT) with an end-to-end choledococholedocostomy. An IS was placed across the biliary anastomosis, passing through the ampulla. We compared the demographic profiles and various outcomes between the 2 groups (no-IS group vs IS group) and examined risk factors associated with anastomotic biliary complications. Results The study comprised 350 patients in the no-IS group and 132 patients in the IS group. Anastomotic biliary fistula (ABF) occurred in 5 (1.4%) and 1 (0.8%) patients in the no-IS group and the IS group, respectively (P = .55). Anastomotic biliary stricture (ABS) occurred in 53 (15.1%) and 18 (13.6%) patients, respectively (P = .68). No significant difference was found in the overall biliary complications between the 2 groups (P = .33). In multivariate logistic regression analysis, acute rejection was the only risk factor for ABS (P = .02). One biliary complication–induced mortality occurred in the no-IS group in which the patient died of an ABF-induced hepatic artery pseudoaneurysm rupture. Conclusion The use of biliary ISs in DDLT did not reduce the overall risk for biliary complications, but more research is needed to draw definite conclusions.

Introduction Uterine transplantation (UTx) is a surgical therapeutic modality designed for the treatment of patients with exclusive uterine factor infertility. Experimental models are paramount to study this transplant modality, and as the ewes' uteri are very similar to that of humans, they are frequently used with this purpose. The aim of this study is to describe a novel technical variation for UTx in sheep. Methods This study was conducted at Laboratory of Medical Investigation 37 of the University of Sao Paulo School of Medicine in Sao Paulo, Brazil, and was approved by the Ethics Committee of Animal Use of the university. We used 3 adult female sheep that weighed approximately 45 kg and were not pregnant. We performed the technique of uterine autotransplantation with a novel technical variation that we called sequential vascularization: first, we performed the right uterine artery and vein anastomoses, after which the uterine graft was vascularized, and then the contralateral vascular anastomoses were performed. Conclusion We described 3 successful uterine autotransplants in sheep models with sequential vascularization. This variation technique will probably allow warm ischemia time in UTx to significantly decrease.

In early piggyback liver transplantation (LT) descriptions, the common stump of the middle and left hepatic veins (ML) was used for upper caval anastomosis. In this variant, stenosis or kinking of graft venous outflow path was frequent. Over time, most authors adopted the use of the recipient’s right, middle, and left hepatic veins (RML) or a side-to-side anastomosis (SS) between the graft’s and recipient’s inferior vena cava (IVC). Nonetheless, partial IVC clamping required in RML and SS can reduce IVC flow. Since 1998, we incorporated a modified piggyback procedure using the recipient’s right and middle hepatic veins (RM) to simultaneously achieve better preservation of IVC flow and a wide and well-positioned anastomosis. Objective The aim of this study is to describe the RM method and to compare this technique with other standard variants of piggyback LT. Method We conducted a retrospective analysis of 477 piggyback LTs classified in 4 groups: ML (n = 102); RM (n = 171); RML (n = 150); and SS (n = 54). Results The incidence of venous outflow block was 3.9% (4/102) in ML, 2.3% (4/171) in RM, 0% (0/150) in RML, and 3.7% (2/54) in SS (P = .049). On Bonferroni multiple comparison analysis, no statistically significant paired difference was identified. Results showed that 1-, 3-, 5-, and 10-year patient survival was 76%, 67%, 63%, and 51% in the ML group; 80%, 71%, 68%, and 62% in the RM group; 77%, 75%, 70%, and 64% in the RML group; and 76%, 76%, 76%, and 70% in the SS group, respectively (P = .193). Conclusion The RM modified piggyback LT technique is feasible and safe.

Objective Secondary lymphedema of the extremities usually develops well after lymph node dissection or radiation therapy in oncologic surgery. In this report, we present a case of lymphedema developed after liver transplantation and treatment by lymphaticovenular anastomosis (LVA). Methods A 52-year-old man was diagnosed with hepatocellular carcinoma in April 2016, and a liver transplantation was performed in June 2016. After the liver transplantation, left lower leg swelling developed, and the symptom became severe for around a year. Two years after liver transplantation, lymphoscintigraphy and indocyanine green lymphography were performed, and the patient was diagnosed with lymphedema caused by proximal lymphatic obstruction. LVA was performed at the ankle and superior knee areas. Results The difference between the left and right knee circumference was decreased from 5.3 cm to 3.4 cm at 6 months postoperatively. The lower extremity lymphedema index of the left leg was decreased from 291.9 to 288.1 at 6 months after surgery. A quality of life measure for limb lymphoedema survey showed that all 4 categories (function, appearance, symptoms, and mood) were improved at 6 months after surgery. Conclusion Lymphedema can develop after liver transplantation, and early LVA surgery can be effective for the treatment of lymphedema developed after liver transplantation.

Background Nearly all publications related to endoscopic treatment of biliary anastomotic stricture after liver transplant have reported cases that can be cannulated. However, very few publications discuss endoscopic treatment of biliary anastomotic stricture (BAS) in which the guide wire does not pass through the stricture site. The purpose of this article is to analyze the long-term outcome of the Rendezvous technique in severe strictures through which guide wires cannot cannulate. Methods Between 2010 and 2017, a total of 29 patients who underwent Rendezvous technique because of severe BAS after liver transplant were included in the study. Results Twenty-nine patients who underwent the Rendezvous technique showed a 100% technical success rate. Ten patients (34.4%) required stent removal; the mean stenting period was 14.9 (SD, 5.6) months (range, 6.65-24.14 months). A total of 19 patients were maintained without stent removal; the stent-maintaining period was 13.1 (SD, 8.4) months (range, 3.48-38.61 months). Two patients receiving left lobe grafts maintained the stents for 27.1 (SD, 16.2) months. In left lobe graft, the duct anastomosis position moves to the right posteroinferior side of the patient. Conclusions Our results suggest that the stenting period of the Rendezvous technique was longer in severe BAS than in cannulated endoscopic retrograde cholangiopancreatography cases. Especially in the left liver, the position of the duct anastomosis changed to the right posteroinferior of the patient. Thus, the donor duct and the recipient duct are angulated, kinking worsens, and the stenting period becomes longer.

Background Multiple graft bile ducts (BDs) and anastomoses have been considered as risk factors for biliary complications after living donor liver transplant (LDLT). Various surgical techniques have been introduced, and most surgeons perform unification ductoplasty for multiple adjacent BDs during LDLT. However, this could cause hemobilia and is difficult to perform when 2 ductal orifices are far apart or show a size discrepancy. Methods Here, we introduce our novel reconstruction technique for multiple adjacent graft BDs and discuss its effects on postoperative outcomes compared with ductoplasty. We compared the clinical outcomes of 2 biliary reconstruction techniques by retrospectively reviewing 58 recipients who underwent LDLT with right lobe grafts using these 2 techniques at our institution between January 2013 and September 2018: group 1 (n = 20) received ductoplasty, and group 2 (n = 38) was treated with dunking with mucosal eversion technique. Results Overall biliary complication rates were 20.0% in group 1 and 10.5% in group 2 (P = .32). Biliary stricture in group 2 was not frequent compared with that in group 1 (7.9% vs 15.0%, P = .398). Moreover, incidence of biliary stricture in group 2 was not different than that in the group using graft with single BD during the same period (P > .624). Conclusions Our novel technique could be a useful method for reconstructing adjacent BDs in LDLT and the best alternative to ductoplasty. Moreover, it seems to be a reasonable option when 2 orifices are far apart or show a size discrepancy.

BACKGROUND In patients undergoing kidney transplantation, ureteral stents are an established technique to reduce major urologic complications such as leakage and stenosis of the ureter. However, the best technique for ureteral stenting remains unclear. The aim of this study was to compare the outcome of percutaneous ureteral stents (PS) with internal double J stents (JJS) after kidney transplantation. METHODS All patients undergoing kidney transplantation between 2005 and 2014 were retrospectively analyzed. After excluding patients

Background Portal vein (PV) reconstruction is a crucial factor in successful living donor liver transplantation (LDLT). In LDLT using the right liver grafts with anatomic PV variations, we sometimes encounter dual PV anastomosis. In this study we describe PV variations of donor liver in detail as well as our experiences with PV reconstruction in right liver grafts with PV variations. Methods We performed LDLT in 149 recipients between 2002 and 2016. PV variations of donor liver were classified into 3 major anatomic patterns, and we retrospectively analyzed the procedure and postoperative complications of PV anastomosis. Results PV variations in donor livers were classified as type A (normal type) in 125 patients, type B (trifurcation type) in 7 (4.7%), and type C (caudal origin of the right posterior branch) in 17 (11.4%). Among 75 right liver grafts, 10 (13.3%) had anatomic PV variations. In 9 of 10 recipients, dual PV of the graft were anastomosed to dual PV branches of the recipient in direct end-to-end fashion. In the remaining recipient, the posterior portal branch of the graft was anastomosed to the recipient portal trunk through the interposed venous graft in end-to-end fashion and the anterior portal branch of the graft was anastomosed to the side wall of the interposed venous graft. These 10 recipients did not develop any postoperative complications associated with PV anastomosis, although 3 of the 149 recipients (2.0%) developed complications associated with PV anastomosis, such as thrombosis and necrosis. Conclusion Dual PV anastomosis of the right liver graft is safe and feasible in LDLT, even in anatomic PV variations.

Background The external iliac vein is the standard site used for venous anastomosis in kidney transplantation. When a pre-transplantation diagnosis of iliocaval thrombosis is established, a different and suitable venous drainage for the renal outflow must be identified for successful transplant. Methods We report 4 cases of kidney transplantation, performed from 2004 to 2016, in recipients presenting with thrombosis of the inferior vena cava and iliac system needing, because of the lack of access for dialysis, urgent kidney transplantations. The splenic vessels were used in all cases for the graft’s vascular anastomosis after splenectomy. Results Kidney transplantation after splenectomy, with anastomosis of the renal vessels to the splenic ones, was completed in all 4 patients. All of the cases were technically successful with good renal function on discharge. During the follow-up, no graft losses were registered as due to thrombotic event or inadequate renal venous outflow. A normal vascular inflow and outflow was confirmed by means of follow-up ultrasound. Two grafts were lost at 31 months and 91 months, both to noncompliance with immunosuppressive therapy. The other 2 are currently functioning well. Notably, the kidney’s position in the left upper quadrant has not caused technical difficulties in urologic reconstruction. Conclusions In our experience, kidney transplantation using splenic vessels for vascular anastomosis is technically feasible and very useful in the setting of complete iliocaval thrombosis.

Introduction Although outcomes of liver transplantation (LT) have improved as the result of progress in surgical procedures, a failure to restore sufficient graft outflow may yield fatal consequences including graft dysfunction and even graft loss to date. In particular, patients with pre-existing obliterated venous drainage, such as those with Budd-Chiari syndrome (BCS), are at high risk of having venous complications followed by conventional LT. In selected cases, the transplant surgeons are compelled to modify the surgical procedures of LT from the conventional procedure. Methods We describe an LT performed in a BCS patient with complete inferior vena cava (IVC) obstruction. A procedure that we named “hanging hepato-atrial anastomosis” was performed, in which 2 major modifications were made. One modification was the dissection of the lower inlet of the right atrium by use of a trans-abdominal approach and hepato-atrial anastomosis. This was performed by exposing the thoracic IVC through a trans-abdominal approach. The other modification was the manufacture of a blind pouch from the graft's infra-hepatic IVC without anastomosis. Results Modifications were made possible as the result of meticulous examination of the patient's vascular anatomy before the operation. Fortunately, the patient had a heavy network of pre-vertebral veins that drained blood from the lower extremity and both kidneys to the azygos–hemi-azygos veins. Conclusions We learned that a meticulous assessment of vascular anatomy and complete understanding of hemodynamics are the keys to the successful LT for BCS in patients with extensive IVC abnormality. Thoracotomy may not be necessary to explore thoracic IVC when performing hepato-atrial anastomosis in LT for BCS.

Background Despite technical developments in transplantation surgery, complete portal vein thrombosis still remains a challenge for restoration of adequate portal vein inflow. Renoportal or varicoportal anastomosis provides an effective alternative solution for patients with complete portal vein thrombosis. This study describes our experience with renoportal and varicoportal anastomosis during liver transplantation. Patients and methods Between January 2014 and May 2016, 5 patients with complete portal vein thrombosis underwent extra-anatomic portal anastomosis. In 3 cases, varicoportal anastomosis was performed and for the others, end-to-end renoportal anastomosis. We used iliac cryopreserved vein grafts to restore portal anastomosis in 3 cases. Epidemiology, risk factors, surgical techniques, complications, and outcomes of these procedures were evaluated over short- and long-term follow-ups. Results The follow-up time is 3 years for our first renoportal case, which was performed in a cadaveric liver transplantation; it was also first nationwide case. The other renoportal anastomosis was practiced in a living donor liver transplantation and the follow-up time is 8 months. The patient and graft survival rates were 100% at the last follow-up. The follow-up times are 10.9 and 4 months for the patients with varicoportal anastomosis. One of these patients died due to recurrence of hepatocellular carcinoma. The other two patients are alive with good graft functions. Conclusion Our experience suggests that reno-varicoportal anastomosis is a useful technique for patients with complete portal vein thrombosis and cryopreserved grafts may be safely used.

We report a transplant of the left lateral liver segments with 3 arteries for a pediatric recipient from a living donor. A 6-month-old female infant was diagnosed with liver cirrhosis secondary to biliary atresia and scheduled for living donor liver transplantation (LDLT; mother as donor). Left lateral hepatectomy was performed at the donor site. The dissection of the left hepatic artery (HA), which was divided immediately after its origin, showed 3 branches for segments II, III, and IV. The arteries for segment II, segment III, and segment IV were anastomosed to the recipient HA. No postoperative complications were observed. The outcome of this case demonstrates that left lateral segments with 3 arteries can be successfully used if proper surgical techniques are applied. From this experience we can recommend "3-in-1 segmental resection" in the donor can be safely done by skilled microvascular surgeons and this technique should be considered for selected cases where multiple tiny arteries supply the graft.

Biliary complications, such as stricture or obstruction, after living-donor liver transplantation (LDLT) remain major problems to be solved. Magnetic compression anastomosis (MCA) is a minimally invasive method of biliary anastomosis without surgery in patients with biliary stricture or obstruction. A 66-year-old woman had undergone LDLT for end-stage liver disease for primary biliary cholangitis 20 months previously at another hospital. Computerized tomography showed dilation of the intrahepatic bile duct (B2). Because B2 was invisible with the use of endoscopic retrograde cholangiopancreatography, percutaneous transhepatic biliary drainage (PTBD) was performed for treatment of cholangitis. The rendezvous technique failed because a guidewire could not pass through the biliary stricture. Therefore, we decided to perform MCA. A parent magnet was endoscopically placed distally in the common bile duct of the stricture, and a daughter magnet attached to a guidewire was inserted proximally through the fistula tract of the PTBD. Both magnets were positioned across the stricture, and the 2 magnets were pulled to each other by magnetic power, to sandwich the stricture. By 14 days after MCA, a fistula between B2 and the common bile duct was created. At 28 days after MCA, the magnets were removed distally and a 16-French tube was placed across the fistula. At 7 months after MCA, that tube was removed. In conclusion, when a conventional endoscopic or percutaneous approach including the rendezvous technique fails, MCA is a good technique for biliary stricture after LDLT.

Background Kidney transplantation is the treatment of choice for patients with end-stage renal disease. The standard surgery uses the recipient's iliac vessels for vascular anastomosis. Thrombosis and/or stenosis of the iliac vein, which are possible complications of multiple vascular access points for dialysis, can be detected intraoperatively, constituting a surgical challenge. An infrequently reported option is the use of the gonadal vein. Objectives This study aims to evaluate the outcomes of venous anastomosis in the gonadal vein in patients with iliac vein thrombosis and/or stenosis submitted to kidney transplantation. Methods. We reviewed the records of five adult recipients with iliac vein thrombosis and/or stenosis detected intraoperatively during emergency kidney transplantation with deceased donor due to vascular access failure from February 2013 to December 2014. Antithrombotic prophylaxis was not performed. We evaluated the postoperative complications, length of stay, early graft echo-Doppler, and renal function during the first year postoperatively. Results Delayed graft function occurred in three cases. Two patients developed postoperative infection requiring antibiotics. One patient required reoperation due to post-renal biopsy complications. The mean length of stay was 31.2 days and the mean serum creatinine levels at discharge, at 6 months, and at 12 months postoperatively were 1.42 mg/dL, 0.86 mg/dL, and 0.82 mg/dL, respectively. All patients had normal ultrasonography. There were no losses of graft or deaths during follow-up. Conclusion Venous anastomosis using the gonadal vein in kidney transplantation for patients with iliac vein thrombosis and/or stenosis showed good clinical and surgical results, showing this method to be a viable alternative to venous drainage in these complex patients.

Background Extravesical Lich-Gregoir ureteroneocystostomy (UC) is the most widely used method for urinary reconstruction during kidney transplantation. Sometimes it is difficult to perform UC in cases with disused atrophic bladder. Pyelo-ureteral anastomosis (PUA) and uretero-ureteral anastomosis (UUA) may be preferred to UC for these patients. Methods We retrospectively reviewed the charts of 833 kidney transplant recipients operated on by our transplantation team between July 2010 and November 2014. The patients were divided into two groups: Group I consisted of 16 patients who underwent end-to-side UUA and Group II consisted of 20 patients who underwent end-to-end UUA. The two groups were compared in terms of efficacy, safety, and graft function. Results As we performed end-to-side UUA as a relatively new technique compared with end-to-end UUA, the post-transplantation follow-up period of Group II was significantly longer than Group I ( P = .000), but all the patients in both groups had at least 1 year of follow-up. Because the first two patients in Group II, who underwent native ureteral ligation without nephrectomy, developed hydronephrosis in their native kidneys, requiring nephrectomy in the post-transplantation period, we performed native nephrectomy in all of the remaining patients in this group. That is why the mean operative time was significantly longer in Group II compared with Group I ( P = .000). There was no significant difference between the two groups in terms of postoperative surgical complications, post-transplantation urinary infections, and graft function. Conclusion End-to-side UUA without native ureteral ligation is a safe surgical technique for urinary tract reconstruction during kidney transplantation in patients with disused atrophic bladder.

Background Portal vein (PV) reconstruction is an important surgical skill for living donor liver transplantation (LDLT), especially for patients with portal vein thrombosis (PVT). However, this technique remains a critical problem in LDLT because of technical demands and requirements for appropriate venous graft harvesting. This study aimed to evaluate the surgical procedure used for PV reconstruction and outcomes in LDLT recipients with PVT. Methods Between March 2002 and December 2018, 128 adult LDLTs were performed. Fourteen recipients (10.8%) had PVT at the time of LDLT, classified as grade I in 2, grade II in 5, grade III in 6, and grade IV in 1, according to the Yerdel classification. We retrospectively analyzed the surgical procedure and postoperative complications associated with PV reconstruction of recipients with PVT. Results Surgical treatments for 14 recipients with PVT were as follows: thrombectomies in 2 recipients, replacement of interpositional venous grafts using the internal jugular vein (IJV) in 3 recipients and the external iliac vein (EIV) in 6 recipients, mesoportal jump grafts using the IJV in 1 recipient and the IJV + EIV in 1 recipient, and renoportal anastomosis using the EIV in 1 recipient. Among interpositional venous grafts, 5 venous grafts (IJV: 2, EIV: 3) passed the dorsal side of the pancreas without using the jump graft. Postoperative complications associated with PV anastomosis occurred in 1 of 14 (7.1%) recipients, who developed anastomosis bleeding caused by coagulation disorders at 27 days after LDLT, without any strictures of PV anastomoses. The overall survival rate at 5 years posttransplant was not statistically different between recipients with and without PVT (50.0% vs 65.0%, P = .163). Conclusion Our techniques of PV reconstruction, using the appropriate venous grafts and route, are feasible, resulting in a prognosis comparable to that of recipients without PVT.

Purpose In living donor liver transplantation, poor compatibility of the recipient hepatic artery remains a technical challenge. Here, we analyzed our 14 years of experience with extra-anatomic hepatic artery reconstruction. Methods Between July 2004 and December 2018, there were 1063 liver transplantations at our center. All patients with an extra-anatomic hepatic artery reconstruction were identified. The gastroduodenal artery and the transposed splenic artery were the primary options for extra-anatomic arterial reconstruction. Patient characteristics, operative data, and post-transplant outcome were reviewed retrospectively. Results There were 22 patients with extra-anatomic hepatic artery reconstruction, 6 with gastroduodenal artery, and 16 with splenic artery. There were 2 major complications: 1 patient underwent early reoperation due to bleeding from the splenic artery trunk and another had an iatrogenic injury to the transposed splenic artery during conversion hepaticojejunostomy. Both were treated successfully with surgery. One patient died perioperatively due to sepsis. The 1- and 3-year graft survival rates of these 16 patients were 93.7% and 87.5%. Conclusion If the hepatic arteries are not suitable for anastomosis, then we consider the gastroduodenal artery and the splenic artery to be the conduits of choice for extra-anatomic arterial reconstruction. The transposed splenic artery is very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis.

Background Hepatic artery occlusion (HAO) is a life-threatening complication after liver transplantation. We report a case of portal vein arterialization (PVA) with anastomosis of the recipient common hepatic artery (CHA) and a graft of the round ligament to achieve intrahepatic arterial flow. Case presentation A 57-year-old man had a medical history of decompensated liver cirrhosis secondary to cholestatic liver disease owing to biliary anastomotic stricture after living donor liver transplantation and end-stage renal failure. He underwent deceased donor liver and renal transplantation with anastomosis of the recipient proper hepatic artery and the graft CHA. He experience symptoms from HAO on postoperative day 23 and underwent emergency surgery to re-anastomose the hepatic artery. Despite several instances of re-anastomoses, intrahepatic arterial flow was not able to be achieved and therefore PVA with anastomosis of the recipient CHA and the graft round ligament was performed. Although liver enzyme levels rapidly declined after surgery and the finding of liver infarction was not observed, a large amount of watery stool was observed owing to portal hypertension, which was an adverse effect of PVA. As enhanced computed tomography on POD 31 showed a pseudoaneurysm of the anastomotic site, occlusion with coils was performed to arrest hemorrhage, and a contrast study after coil occlusion showed intrahepatic arterial blood flow via collateral arteries. Thereafter, the patient needed treatment for ischemic biliary duct stenosis and was discharged home on POD 98. Conclusion PVA using a round ligament for HAO after liver transplantation might play a role as a bridge treatment until retransplantation or maturation of collaterals.

Anastomotic airway complications after lung transplantation affect up to 20% of patients. Bronchial stenosis is the most frequent complication, while dehiscence of bronchial anastomosis is a rarely seen complication, with report incidences between 1% and 10%. Despite its low incidence, dehiscence of bronchial anastomoses remains a disastrous complication in the posttransplantation period without a well-established management protocol. We present a challenging case of complete bronchial dehiscence after unilateral lung transplantation in a patient with interstitial lung fibrosis (ILF) that occurred on postoperative day 10. The dehiscence was diagnosed early and the patient's status was stable for repeat thoracotomy, therefore, an early surgical approach was preferable to conservative management or bronchoscopy. Aggressive early surgical management in a stable patient allows for complete debridement with removal of the detritus that impedes correct anastomosis healing and permits the removal of microbial vegetations with successful results.

Variations of the anatomy of donor hepatic arteries increase the number of arterial anastomoses during liver transplantation and, possibly, the incidence of hepatic artery thrombosis (HAT). In this study, we describe the arterial anatomic variations in liver grafts procured and transplanted by a single center in Greece, the techniques of arterial anastomosis, and their effect on the incidence of early HAT.From January 2013 to December 2017, the arterial anatomy of 116 grafts procured for liver transplantation were recorded, as well as the technique of arterial anastomosis and the incidence of early hepatic artery thrombosis (HAT 30 days).A single hepatic artery was recorded in 72.41% of the procured grafts, an aberrant left hepatic artery (accessory or replaced) in 18 grafts (15.52%), and an aberrant right hepatic artery (accessory or replaced) in 17 grafts (14.66%), while other variations were observed in less than 1% of the procured livers. Of the 116 primary liver transplantations, 6 patients (5.17%) developed early HAT 30 days. Two of these patients (1.72%) had 1 anastomosis of the hepatic artery and 4 (3.45%) had 2 anastomoses due to anatomic variations.Anatomic variations of the hepatic artery in liver grafts is a common finding and increase the incidence of early HAT but not to a degree to make these grafts unusable.

Although Roux-en Y hepaticojejunostomy was previously recommended for the biliary reconstruction in liver transplantation for primary sclerosing cholangitis (PSC), some recent reports showed no difference in the graft survival between Roux-en Y and duct-to-duct anastomosis in deceased-donor liver transplantation. On the other hand, considering the risk of recurrence and the short length of the bile duct of the graft, duct-to-duct biliary anastomosis has never been reported in a patient undergoing living-donor liver transplantation (LDLT) for PSC. A 45 year-old male underwent LDLT using a left-lobe graft donated from his brother. Cholangiography showed no lesion in his common bile duct and duct-to-duct anastomosis was chosen for him. Fifteen months later, he suffered cholangitis due to PSC recurrence and endoscopic retrograde cholangiography was performed. The stents were inserted into his B2 and B3, and he remains well. Because of the ability to easily manage biliary complication, duct-to-duct biliary reconstruction may become the first choice in LDLT for PSC without common bile duct lesions.