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Backgrounds/Aims While minimal invasive surgery has become popular, the feasibility of laparoscopy for liver cavernous hemangioma has not been shown. Methods Patients who underwent hepatectomy for liver cavernous hemangioma from January 2008 to February 2019 at the Samsung Medical Center were reviewed. Patients who underwent trisectionectomy were excluded. Background characteristics, along with operative and postoperative recovery, were compared between the laparoscopy and open surgery groups. Results Forty-three patients in the laparoscopy group and 33 patients in the open surgery group were compared. The differences in the background characteristics were presence of symptoms (14.6% in laparoscopy vs. 57.1% in open, p

Introduction There is still no consensus about the actual role of liver transplantation (LT) in the therapeutic algorithm of combined hepatocellular-cholangiocarcinoma (cHCC-CC) because of low incidence and few clinical information. Methods We retrospectively identified 111 patients at nine centers from 2001 to 2019 in Korea. Results Of the 111 patients, 85.6% (n = 95) was male and the median age was 54 years (range, 31-66 years). HBV is 82% (n = 91) and HCC is 96% (86.3%) preoperatively. Seventy-four patients (66.7%) received locoregional therapy (LRT) before LT. Median tumor size was 2.5 cm (range, 0.5-7.2 cm) and the ratio of beyond Milan criteria was 40.5% (n = 45). The 1-year, 3-year, and 5-year disease-free survival rates and tumor-related patient survival rates were 77.6%, 56.3%, and 51.1% and 84.4%, 63.8%, and 56.7%, respectively. The extrahepatic site was 75.5% as an initial tumor recurrence site in recurrent tumor patients. Numbers of LRT before LT > 3 and tumor size > 3 cm were closely associated tumor recurrence and early tumor recurrence within 1 year after LT. Tumor size > 3 cm was only predisposing factor for tumor-related death. Conclusions It is difficult to diagnose cHCC-CC before LT, but a good prognosis can be expected if the tumor size is less than 3 cm in pathology.

Introduction For the APRI and FIB-4 index, which are one of the non-invasive methods of examining the degree of liver fibrosis, our paper aims to examine the implications for predicting the prognosis in hepatocellular carcinoma patients undergoing hepatectomy. Methods Between 2006 and 2013, total 973 patients were underwent hepatic resection due to hepatocellular carcinoma and 871 patients were enrolled in our study after adjusting exclusion criteria. Statistics were performed by calculating the optimal cut off values for the recurrence free survival and overall survival of each group which are categorized by etiology and multivariate analysis were performed for evaluating the performance of index. Results Among the causes of HCC patients, HBV (n = 629, 72%) was the most common, and men were dominant in all groups. In each group divided by etiology, the area under the receiver operating characteristics of APRI and FIB-4 for recurrence free survival and overall survival were relatively higher in HCV patients than in other groups. After setting the cut-off value through the Youden index, univariate analysis and multivariate analysis for RFS and OS of all groups were performed, and the results of APRI values for RFS in each group were statistically significant (HBV : OR = 1.849, p = 0.001; HCV : OR = 6,548, p = 0.010; Alcohol : OR = 3.393, p = 0.004). Conclusions The significance of this study is that these simple laboratory findings are meaningful in revealing the prognosis of HCC patients, which can be predicted accurately only after the pathologic staging after surgery.

Introduction Old donors have gradually been used as an alternative living liver donor to alleviate the organ shortage or avoid offspring donation. The aim of the present study is to determine the impact of elderly donors more than 60 years in living donor liver transplantation (LDLT) on donor safety and recipient outcomes compared with donors from fifty to fifty-nine years. Methods We retrospectively identified 209 patients at nine centers from 2005 to 2017 in Korea. Results Sixty group represented 10.0% (n = 21) of the patient donors. The incidence of male donor in the sixty group was higher than in the fifty group (61.9% vs. 37.8%; p = 0.039). Postoperative complications were more common in the sixty group. There was no in-hospital mortality and no mortality was reported during the observation period. There were no statistically significant differences in operation time, blood loss, intraoperative and postoperative transfusion rate, postoperative total bilirubin, and hospitalization between the two groups. In recipient operation, median blood loss, transfusion rates during operation, and postoperative bleeding control operations were more than in the fifty group. Postoperative total bilirubin and hospitalization in the sixty group were higher and longer in the fifty group. Cumulative patient survival rate in the fifty group was better than in the sixty group (p = 0.011). Sixty group was predisposing factor for recipient death in multivariate analysis. Conclusions Present study suggests that highly selected elderly living donors (≥ 60 years) can safely donate, but their recipient outcomes are worse compared with the fifty group.

Introduction As the general population continues to age, elderly patients have dramatically increased for detecting hepatocellular carcinoma (HCC) and required for surgical management. The aim of this study was to compare the postoperative and long-term outcomes of hepatectomy those patients according to the operation time. Methods This study included 130 elderly patients who underwent surgical resection for solitary, treatment-naive HCC between November 1998 and March 2020. Group 1 was defined as patients undergoing LR before 2016 (n = 68) and Group 2 was defined as those undergoing liver resection (LR) after 2016 (n = 62). Results The proportion of major LR and laparoscopic LR in the Group 2 were significantly higher than in the Group 1. Median operation time and blood loss during operation in the Group 2 were smaller than in the Group 1. In addition, intraoperative red blood cell (RBC) transfusion rate, complication rates, and median hospitalization in Group 2 were significantly lower than Group 1. The disease-free survival and patient survival in the Group 2 were better than in the Group 1 even though the presence of tumor grade 3 or 4 and the incidence of microvascular invasion in the Group 1 were higher than in the Group 2. Group 1, long hospitalization, presence of satellite nodule, and intraoperative RBC transfusion were predisposing factors for patient death. Conclusions Laparoscopic LR in elderly HCC patients, was performed more frequently than in the past, resulting in an increase in the number of liver surgeries and improved survival.

Introduction Surgical resection is one of the curative options for hepatocellular carcinoma (HCC). Posterosuperior segmentectomy is defined as anatomical resection of the liver segments 7 and 8. However, minimally invasive resection of posterosuperior liver segments is considered a difficult and complex operation and is therefore rarely reported. Methods We present a video of laparoscopic posterosuperior segmentectomy of the liver (S7, 8) due to HCC, in a 66-years old male patient. Liver mobilization was performed with exposure of the inferior vena cava. Intraoperative ultrasound was used to locate the tumor and identify its relationship with the portal veins of segments 7 and 8. The liver parenchyma was divided using ultrasonic energy device and the Glissonean pedicles were ligated using hem-o-lock and surgical clips. The surgical specimen was removed through a lower midline incision. Results Operative time was 162 minutes, and the estimated blood loss was 400 mL. The patient recovered without problems such as admission to the intensive care unit or blood transfusion. Pathology confirmed progressed HCC. Conclusions Laparoscopic posterosuperior segmentectomy is difficult, but is feasible and safe. This video can help inexperienced surgeons perform this complex procedure.

Introduction This study was designed to analyze the risk factors for poor survival after recurrence of hepatocellular carcinoma after liver transplantation. Methods Patients who underwent liver transplantation for hepatocellular carcinoma during the period of 2007 to 2018 were reviewed and patients who experienced recurrence were included. Multivariable Cox proportional hazard ratio were performed for potential risk factors for survival after recurrence. Pre-transplantation characteristics as well as variables related to the recurrence and treatment for recurrence were included for the analysis. Results A total of 151 liver transplantation recipients experienced hepatocellular carcinoma recurrence after liver transplantation. Median duration of recurrence-free period was 9.3 months (0.89 to 97.25 months). Median follow up duration after recurrence was 13.4 months (0.59 to 118.28 months). One-, 3-, and 5-year survival after recurrence were 65.2%, 34.0% and 20.5%, respectively. Multivariable Cox analysis showed that, graft from living donor (HR = 0.364, CI = 0.177-0.748, p = 0.006), recurrence-free interval ≥ 9 months (HR = 0.273, CI = 0.174-0.428, p < 0.001), alpha-fetoprotein ≥ 100 ng/mL at the time of recurrence (HR = 1.816, CI = 1.158-2.848, p = 0.009), and bone metastasis (HR = 2.031, CI = 1.237-3.334, p = 0.005) were related to survival after recurrence. In patients with solitary metastasis of single organ, recurrence-free interval ≥ 9 months (HR = 0.212, CI = 0.091-0.493, p < 0.001), multiple tumor in the extracted liver (HR = 3.409, CI = 1.457-7.974, p = 0.005), and lymph node metastasis (HR = 4.688, CI = 1.671-13.156, p = 0.003) were related to survival after recurrence. Conclusions Although the survival was generally poor after recurrence of hepatocellular carcinoma in liver transplantation recipients, prolonged survival can be achieved in certain patients with better prognostic factors. Therefore, appropriate treatment should be performed even with transplantation recipients with hepatocellular carcinoma recurrence.

Introduction This study was designed to build a model predicting graft survival after liver transplantation. Methods Multivariable Cox proportional hazard models for predicting graft survival after living donor and deceased donor liver transplantation using post-transplantation aspartate aminotransferase (AST), total bilirubin (TB), and international normalized ratio (INR) of prothrombin time were performed, respectively. The models were compared with MEAF score and early allograft dysfunction (EAD) criteria. Results A multivariable model including log2-transformed variables of maximum AST from days 0 to 7 post-transplantation and maximum TB and maximum INR from days 3 to 7 was predictive of graft survival both in living donor (C-index = 0.729) and deceased donor liver transplantation (C-index = 0.739). C-index of living donor model was significantly higher compared to both MEAF score (C-index = 0.692, p = 0.0305) and EAD criteria (C-index = 0.661, p = 0.0015). Time-dependent AUC at 2 weeks of living donor model (AUC = 0.961) was significantly higher compared to EAD criteria (AUC = 0.834, p < 0.0001). Time-dependent AUC at 4 weeks of living donor model (AUC = 0.926) was significantly higher compared to both MEAF score (AUC = 0.865, p = 0.0246) and EAD criteria (AUC = 0.842, p = 0.0220). C-index of deceased donor model was significantly higher compared to EAD criteria (C-index = 0.661, p = 0.0015). Time-dependent AUC at 2 weeks of deceased donor model (AUC = 0.978) was significantly higher compared to EAD criteria (AUC = 0.834, p < 0.0001). Time-dependent AUC at 4 weeks of deceased donor model (AUC = 0.942) was significantly higher compared to both MEAF score (AUC = 0.820, p = 0.0239) and EAD criteria (AUC = 0.810, p ≤ 0.0001). Conclusions The multivariable prediction model for graft survival after liver transplantation showed high predictability and validity with higher predictability compared to the traditional models.

Introduction Inadequate liver volume and weight is a major source of morbidity and mortality after adult living donor liver transplantation (LDLT). The purpose of our study was to investigate HCC recurrence, graft failure, and patient survival according to change in right liver graft weight after histidine-tryptophan-ketoglutarate (HTK) solution perfusion in LDLT. Methods Two hundred twenty-eight patients underwent LDLT between 2013 and 2017. We calculated the change in graft weight by subtracting pre-perfusion graft weight from post-perfusion graft weight. Patients with increased graft weight were defined as the positive group, and patients with decreased graft weight were defined as the negative group. Results After excluding patients who did not meet study criteria, 148 patients underwent right or extended right hepatectomy. The negative group included 89 patients (60.1%), and the positive group included 59 patients (39.9%). Median graft weight change was -28 g (range, -132-0 g) in the negative group and 21 g (range, 1-63 g) in the positive group (p < 0.001). Median hospitalization time was longer for the positive group than the negative group (27 days vs. 23 days; p = 0.048). There were no statistical differences in tumor characteristics, postoperative complications, early allograft dysfunction, or acute rejection between the two groups. Disease-free survival, death-censored graft survival, and patient survival were lower in the positive group than the negative group. Additionally, the positive group showed strong association with HCC recurrence, death-censored graft survival, and patient survival in multivariate analysis. Conclusions This study suggests that positive graft weight change during HTK solution perfusion indicates poor prognosis in LDLT.

Introduction Several treatments have recently been known for hepatocellcular carcinoma (HCC) who have failed to treat sorafenib. Immune checkpoint inhibitors have proven to be effective, but data on the safety and efficacy of liver transplant (LT) patients are limited. We aimed to report the effect of nivolumab after failure of sorafenib treatment in patients with recurrent HCC after liver transplantation. Methods This study retrospectively evaluated patients who failed sorafenib for recurrent HCC treatment after liver transplantation in a single center from March 2007 to December 2018. Patients with recurrent hepatocellular carcinoma after liver transplantation who received regorafenib or nivolumab after sorafenib treatment failure were included. Results Of the 53 study patients, 8 received regorafenib and 10 received nivolumab. There is no difference in the characteristics of the two groups. Median overall survival (OS) from LT or HCC recurrence was 58.1 months and 40.2 months in the novolumab group and was 25.6 months and 17.6 months in the non-nivolumab group (p = 0.104 and p = 0.143, respectively). The median OS from nivolumab use was 5.3 months and the median OS from sorafenib use in non-nivolumab group was 14.8 months (p = 0.657). All 10 patients receiving nivolumab failed to control HCC progression and 6 patients (60%) were dead due to HCC progression during a median follow-up period of 2.4 months (interquartile range, 1.8-7.2 months) from the onset of nivolumab. Conclusions Present study suggests that the use of nivolumab in LT patients with recurrent HCC has not shown a clear function in inhibiting HCC progression yet.

Introduction Although hepatocellular carcinoma (HCC) is rare in hepatitis C virus (HCV) patients without cirrhosis, little is known about the postoperative results of these patients. We performed this study to compare the outcomes of cirrhotic and non-cirrhotic HCV patients with solitary treatment-naive HCC and to assess ability of non-invasive markers to predict prognosis in these patients. Methods Two hundred seven adult hepatectomy patients with HCV-related HCC were prospectively identified at our institution between July 2005 and May 2019. Results One hundred sixteen (56%) hepatectomy patients had HCC in a non-cirrhotic liver. The non-cirrhotic group had better liver function than the cirrhotic group. Consistently, the FIB-4 grade, ALBI grade, and APRI were higher in the cirrhotic group than in the non-cirrhotic group. The cumulative disease-free survival rates and patient survival rates in the non-cirrhotic group were significantly better than in the cirrhotic group. HCC recurrence is related to major liver resection (LR) and alpha-fetoprotein (AFP) > 40 ng/mL, death is related to long hospitalization, and AFP > 40 in multivariate analysis. APRI was the only predisposing factor for HCC recurrence in non-cirrhotic patients in multivariate analysis. The FIB-4 grade, ALBI grade, and the presence of cirrhosis were not related to HCC recurrence or patient survival in multivariate analyses. Conclusions The non-cirrhotic group had a higher survival than the cirrhotic group after curative LR, although the difference was not significant in multivariate analysis. The factors influencing HCC recurrence and patient survival were different in the cirrhotic and non-cirrhotic groups.

Introduction This study is designed to analyze the feasibility of laparoscopic living donor right hemihepatectomy in living donors with portal vein variation. Methods Living donor liver transplantation cases with right liver graft during the period of January 2014 to September 2019 were included. Computed tomographic angiographies of the donor were three-dimensionally reconstructed, and the anatomical variation of the portal vein was classified. To reduce, selection bias, 1:1 ratio propensity score match analysis between the laparoscopy group and the open group was performed. Surgical and recovery-related outcome as well as portal vein complication-free survival, graft survival and overall survival were analyzed. Results After matching, 171 cases in each group from 444 original cases were compared. The laparoscopy group had shorter operation time (p < 0.001), smaller number of additional opioids required by the donor (p < 0.001), shorter hospital stay (p < 0.001). There were no difference in the portal vein complication-free survival (p = 0.16), graft survival (p = 0.26), and overall survival (p = 0.53). While portal vein complication-free survival was inferior in portal vein other than type I (p = 0.01), the laparoscopy showed similar portal vein complication-free survival whether the portal vein was type I (p = 0.35) or other types (p = 0.30). Conclusions Laparoscopic living donor right hemihepatectomy can be performed as safely as open surgery regardless of the anatomical variation of portal vein.

Backgrounds/Aims This study aims to compare differences between laparoscopic donor right hemihepatectomy (LDRH) and open donor right hemihepatectomy (ODRH) in the quality of the operation, postoperative complications, and liver regeneration measured via volumetry. Methods This study included 119 patients who underwent living donor right hemihepatectomy at Samsung Medical Center from January 2016 to December 2017. We compared several aspects of LDRH and ODRH and analyzed the results using the independent t-test, chi-square test and Fisher's exact test. Results Among 119 enrolled patients, 66 patients (55.5%) underwent open surgery, and 53 patients (44.5%) underwent laparoscopic surgery. The mean operation time was significantly shorter for ODRH (290.57±54.04 minutes) than LDRH (312.28±53.5 minutes) (p=0.031). Estimated blood loss was significantly less in LDRH (258.49±119.99 ml) than ODRH (326.52±157.68 ml) (p=0.011). The remnant liver recovered to 83.35±10.71% of the preoperative estimate whole liver volume (pre-EWLV) in the ODRH group and 84.04±8.98% of the pre-EWLV in the LDRH group (p=0.707). The percentage of increased estimated liver volume to postoperative estimate remnant liver volume (post-ERLV) was 137.62±40.34% in the ODRH group and 130.56±36.78% in the LDRH group, and there was no statistically significant difference between the two groups (p=0.326). An analysis of postoperative complications showed no significant differences. Conclusions LDRH is safe, and there is no significant difference in hepatic regeneration compared with ODRH. Therefore, LDRH can be applied for living donation of liver.