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The indication of liver transplantation (LT) for the treatment of advanced hepatocellular carcinoma (HCC) is expanding. However, portal vein tumor thrombus (PVTT) has been still accepted as an absolute contraindication. We experienced an unexpectedly good prognosis in selected patients. Therefore, we tried to identify the prognostic factors after LT for HCC with major PVTT. Among 282 patients who underwent living donor liver transplantation (LDLT) for HCC from January 2009 to December 2013, 11 (3.9%) patients with major PVTT that was preoperatively diagnosed were investigated. The 1-, 3-, and 5-year recurrence-free survival rates were 63.6%, 45.5%, and 45.5%, respectively, and all recurrent cases showed intrahepatic and extrahepatic recurrence. The 1-, 3-, and 5-year overall survival rates were 72.7%, 63.6%, and 63.6%, respectively, and 2 patients with delayed recurrence survived approximately 5 years after LT. Main portal vein (PV) invasion (P

Liver transplantation is an effective treatment modality for hepatocellular carcinoma (HCC). Due to deceased organ shortage, living donor liver transplantation (LDLT) accounts for the majority of liver transplants in Korea. The aim of this study is to evaluate the recent trend of LDLT for HCC, and to suggest guidelines and criteria for selecting the appropriate candidates for LDLT.Between January 2000 and December 2015, 532 patients underwent LDLT for HCC. Clinicopathologic data were analyzed as well as overall survival rate (SR) and disease-free survival rate (DFSR) according to the Milan criteria based on explant pathology, positron emission tomography (PET) positivity, and serum alpha-fetoprotein (AFP) level.The 5-year overall SR and DFSR were 81.5% and 75.5% respectively. According to our previously reported combination of AFP and PET [Seoul National University Hospital (SNUH) criteria]; low risk group [AFP200 ng/mL, PET (-)], intermediate risk group [AFP200 ng/mL, PET (-) or AFP200 ng/mL, PET (+)], and high risk group [AFP200 ng/mL, PET (+)], the 5-year DFSR of low risk group was 86.1%, intermediate risk group was 79.0%, and high risk group was 18.5% (P0.001). Within the Milan criteria, the 5-year DFSR of low risk group was 88.4%, intermediate risk group was 79.9%, and high risk group was 60.0% (P=0.016). Beyond the Milan criteria, the 5-year DFSR of low, intermediate, and high risk group was 80.3%, 77.7%, and 9.1%, respectively (P0.001).In conclusion, our data and experience suggest that a continued paradigm shift from a conventional size based criteria to a biological marker based criteria is indicated when evaluating LDLT candidates with HCC.

Pure laparoscopic donor hepatectomy (PLDH) has become increasingly accepted in the era of minimally invasive surgeries. However, the outcomes of pure laparoscopic donor left hepatectomy (PLDLH) are relatively less known than for left lateral sectionectomy or right hepatectomy. This study aimed to report our experience with and the outcomes of PLDLH including the middle hepatic vein (MHV) and to compare these outcomes with conventional donor left hepatectomy (CDLH). The medical records of living liver donors between January 2010 and January 2018 at Seoul National University Hospital were retrospectively reviewed. Donors who underwent left hepatectomy including the MHV were included. To minimize selection bias, donors who underwent CDLH after the initiation of the PLDH program were excluded. Finally, there were 18 donors who underwent CDLH and 8 who underwent PLDLH. The median (interquartile range [IQR]) warm ischemia time (11 [10-16] minutes versus 4 [2-7] minutes; P = 0.001) was longer in the PLDLH group than the CDLH group. The total operation time (333 [281-376] minutes versus 265 [255-308] minutes; P = 0.09) and time to remove the liver (245 [196-276] minutes versus 182 [172-205] minutes; P = 0.08) were also longer in PLDLH although not statistically significant. The length of postoperative hospital stay was significantly shorter in the PLDLH group (7 [7-8] days versus 9 [8-10] days; P = 0.01). There were no postoperative complications in the PLDLH group. The rate of complications in recipients was similar in both groups. In conclusion, PLDLH including the MHV appears to be safe and feasible. Further analysis including longterm outcomes is needed.

Background Some patients with hepatocellular carcinoma (HCC) recurrence after LT show good long-term survival. We aimed to determine the prognostic factors affecting survival after recurrence and to suggest treatment strategies. Methods Between January 2000 and December 2015, 532 patients underwent adult living donor liver transplantation (LDLT) for HCC. Among these, 92 (17.3%) who experienced recurrence were retrospectively reviewed. Results The 1-, 3-, and 5-year survival rates after recurrence were 59.5%, 23.0%, and 11.9%, respectively. In multivariate analysis, time to recurrence >6 months and surgical resection after recurrence were related to longer survival after recurrence, while multi-organ involvement at the time of primary recurrence was related to poorer survival. We classified patients into early (≤6 months) and late (>6 months) recurrence groups. In the early recurrence group, tumor size >5 cm in the explant liver, liver as the first detected site of recurrence, and multiple organ involvement at primary recurrence were related to survival on multivariate analysis. In the late recurrence group, mammalian target of rapamycin inhibitor (mTORi) usage and multi-organ involvement were significantly associated with the prognosis on multivariate analysis. Conclusions Various therapeutic approaches are needed depending on the period of recurrence after LT and multiplicity of involved organs.

Background Several studies have reported that solid organ transplant recipients have a high risk for malignant tumors because the suppressed immune system fails in preventing malignant transformations. De novo malignancy after transplantation is the most common cause of death in the late period after liver transplant (LT). This study investigated the clinical significance of de novo malignancy after LT, and it is the largest study based in Korea to report long-term follow-up results associated with de novo malignancy after LT. Methods Data of 1793 adults who underwent LT in Seoul National University Hospital were retrospectively collected, and medical charts and data from the Ministry of Public Administration and Security were reviewed to examine the causes of death and de novo malignancy status. The Fisher exact test and Kaplan-Meier survival analysis were used to analyze the data. Results Of the 1793 recipients, 27 died of de novo malignancies. Of 875 hepatocellular carcinoma (HCC) patients, 12 died, and of 918 non-HCC patients, 15 died. De novo malignancy was the main cause of death at 5 years after LT but was not in the initial 5 years. In Korea the most common cancers that developed after LT were gastric cancer (21.4%) and lymphoma (14.3%). De novo HCC in non-HCC cases was found in 2 patients. Conclusion De novo malignancy is a key factor affecting long-term survival after LT. Therefore, regular screening and education are important for improving long-term survival and quality of life in these patients after LT.

Lee et al. (Liver Transpl 10(9):1158–1162, 2004) reported high hilar dissection (HHD) technique as a novel method for recipient hepatectomy to overcome limitations of conventional hilar dissection (CHD). HHD allowed performing multiple tension-free biliary anastomoses and easy reconstruction of double portal vein orifices. However, longer anhepatic phase is its main drawback. We describe a new modification of original HHD, called left portal vein flow preserving HHD (LFP-HHD). The new technique aims to gain the balance between CHD and original HHD. The detailed technique of recipient hepatectomy by LFP-HHD is shown in the electronic video file. It involves high intrahepatic division of hilar structures while maintaining portal drainage through maintained left portal vein (LPV). Control of right hemi-liver inflow allows for division of right hepatic vein, and safe dissection of inferior vena cava (IVC) and hilar structures. According to coordination with donor surgery, the liver could be easily explanted. LFP-HHD has the same principle of original HHD allowing for multiple tension-free well-vascularized biliary anastomoses. LFP-HHD allows for shortening of anhepatic phase duration as portal venous drainage is continued through maintained LPV avoiding prolonged total portal clamping with bowel edema or the need for temporary porto-caval shunt. On the other hand, the number and the length of the hilar structures can be decreased compared with the original HHD technique. However, the level of division of the hilar structures is acceptable in most of the cases. LFP-HHD is a novel simple technique for recipient hepatectomy that can be tailored for certain clinical conditions.

Right lobe (RL) living donor liver transplantation (LDLT) usually includes 2 bile duct anastomosis sites, namely, the right anterior and the right posterior segmental ducts. This study aimed to evaluate the optimal treatment for biliary strictures following RL LDLT with respect to unilateral or bilateral drainage techniques. From January 2005 to December 2017, 883 patients at Seoul National University Hospital underwent RL LDLT. Of these, 110 patients were enrolled who had 2 duct-to-duct anastomosis sites and who were considered at risk of developing biliary anastomotic strictures. Unilateral or bilateral biliary drainage during the follow-up period was identified by endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous transhepatic biliary drainage (PTBD). The clinical success, complication, and 180-day mortality rates were compared between the unilateral and bilateral biliary drainage groups according to the initial ERCP findings. The mean age at the time of LDLT was 54.2 ± 8.2 years. The median time from LDLT to initial biliary anastomotic strictures was 177 (interquartile range, 18-1085) days. At the initial ERCP, unilateral drainage was performed in 55 (50.0%) patients, and bilateral drainage was performed in 11 (10.0%) patients. Of the patients who underwent unilateral drainage, 35 (63.6%) patients required conversion to bilateral drainage during follow-up. Overall, 71 (64.5%) patients required bilateral drainage more than once, whereas only 27 (24.5%) patients reached a resolution with unilateral biliary drainage. In this study, most patients required bilateral biliary drainage more than once during follow-up. An active attempt should be made to drain bilaterally in patients with biliary anastomotic strictures following RL LDLT.

Chronic hepatitis B virus (HBV) is the leading cause of hepatocellular carcinoma (HCC). Covalently closed circular DNA (cccDNA) is an intermediate in the life cycle of HBV. HBV-encoded X protein (HBx), a key viral oncoprotein, can be specifically ubiquitylated by male specific lethal 2 (MSL2), which causes upregulation of HBx activity and promotes transcription, cell proliferation and tumor growth. The present study compared the levels of cccDNA, MSL2 mRNA and HBx mRNA in tumor and peri-tumor tissues, and clarified the effect of antiviral therapy on these indicators. Levels of intrahepatic cccDNA, MSL2 mRNA and HBx mRNA were determined using quantitative PCR in patients with HBV-associated HCC who had undergone liver surgery. A total of 50 patients were included in the present study. Prior to surgery, 31 patients had undergone antiviral treatment. Intrahepatic cccDNA levels were significantly higher in the tumor tissues compared with the peri-tumor tissues (P=0.001), particularly in the hepatitis B e antigen-positive (P=0.008), tumor recurrence (P=0.002) and

Although the use of pure laparoscopic donor hepatectomy (PLDH) is increasingly common, it remains limited to a few experienced centers and no data on the learning curve are currently available. The aim of this study is to evaluate the learning curve associated with the use of pure laparoscopic donor right hepatectomy (PLDRH). Data from donors undergoing PLDRH performed by a single surgeon between November 2015 and October 2017 were retrospectively reviewed. The learning curve was evaluated using the cumulative sum (CUSUM) method based on duration of surgery. Of 100 donors evaluated, none required transfusion or conversion to open hepatectomy and no irreversible disability or mortality was reported. The mean operative time was 320.7 ± 51.8 min, and all grafts were successfully transplanted. The CUSUM analysis demonstrated a learning curve of approximately 60 cases of PLDRH. Estimated total liver volume > 1400 cm3 and double portal vein orifices were seen to be risk factors for longer surgery time. Having adjusted for case mix with these factors, the risk-adjusted CUSUM analysis demonstrated a learning curve of 65–70 cases of PLDRH. In conclusion, PLDRH is a feasible and safe procedure with a learning curve of 65–70 cases.

To determine whether hepatic extracellular volume fraction (ECV) obtained from iodine density map (ECV-iodine) can be used to estimate hepatic fibrosis grade and to compare performance with ECV measured using Hounsfield units (ECV-HU).From December 2016 to March 2019, patients who underwent liver resection or biopsy within four weeks after spectral liver CT were included. ECV-iodine and ECV-HU were calculated using the equilibrium phase. Within each of these, comparison of ECVs was made for different fibrosis grades (F0 - 1 vs. F2 - 3 vs. F4) and also for patients with compensated and decompensated cirrhosis. The diagnostic performance of ECVs in detecting clinically significant fibrosis (≥ F2) and cirrhosis (F4) was assessed using ROC analysis.A total of 144 patients (men = 98, mean age 58.1 ± 11.5 years) were included. The ECV-iodine value was significantly higher in cirrhosis (33.6 ± 6.8 %) than those with F0 - 1 (25.0 ± 3.7 %) or F2 - 3 (28.3 ± 3.4 %, P0.001 for all). It was significantly higher in decompensated cirrhosis than those with compensated cirrhosis (36.5 ± 7.2 % vs. 30.7 ± 5.0 %, respectively; P0.001). The AUC of ECV-iodine was 0.82 for detecting F2 or above (cut-off value,26.9 %) and 0.81 for detecting cirrhosis (cut-off value,29 %). ECV-iodine had a significantly higher AUC than ECV-HU for detecting F2 or above (AUC: 0.69, P 0.001) and cirrhosis (AUC: 0.74, P = 0.04).ECV-iodine from spectral CT was able to detect clinically significant hepatic fibrosis and cirrhosis.

OBJECTIVE The aim of the study was to present the safety and feasibility of pure laparoscopic donor right hepatectomy (PLDRH) in comparison with those of conventional donor right hepatectomy. SUMMARY BACKGROUND DATA Although the use of PLDRH is gradually spreading worldwide, its outcomes, including the long-term outcomes in both donors and recipients, have not yet been evaluated in a large comparative study. METHODS We retrospectively reviewed the medical records of 894 donors who underwent living donor liver transplantation between January 2010 and September 2018 at Seoul National University Hospital. We performed 1:1 propensity score matching between the PLDRH and conventional donor right hepatectomy groups. Subsequently, 198 donor-recipient pairs were included in each group. RESULTS The total operation time (P < 0.001), time to remove the liver (P < 0.001), and warm ischemic time (P < 0.001) were longer in the PLDRH group. None of the donors required intraoperative transfusion or experienced any irreversible disabilities or mortalities. The length of postoperative hospital stay was significantly shorter in the PLDRH group (P < 0.001). The rate of complications in donors was similar between the 2 groups. Although other complication rates in recipients were, however, similar, the rates of early (P = 0.019) and late (P < 0.001) biliary complications in recipients were higher in the PLDRH group. There was no significant difference in overall survival and graft survival between the 2 groups. CONCLUSIONS PLDRH is feasible when performed at an experienced living donor liver transplantation center. Further studies on long-term recipient outcomes including biliary complications are needed to confirm the safety.

Background: The aim of the study was to measure bench-surgery time in pure laparoscopic donor right hepatectomy (PLDRH) in comparison with those of conventional donor right hepatectomy (CDRH). Methods: We retrospectively reviewed the medical records of 514 donors who underwent living donor liver transplantation be tween January 2012 and December 2019 at Seoul National University Hospital. We divided it into two periods: when almost only CDRH was performed and the second period during which PLDRH was standardized. Results: The mean bench-surgery time (49.3 vs. 39.5 minutes; P=0.00) was longer in the PLDRH group than the CDRH group. We performed the analysis while excluding the factors affecting the bench-surgery time in both groups. First, we analyzed except the patients who had undergone direct venoplasty or Y-graft patch reconstruction of two portal veins. After that, we excluded the pa tients who had reconstruction of more than three openings of middle hepatic vein tributaries and no reconstruction of those (right hemi-liver graft). Lastly, we excluded the patients who underwent venoplasty of inferior hepatic vein(s) in back-table procedures. In all three subgroup analyses, the mean bench-surgery time was also longer in the PLDRH group than the CDRH group (47.4 vs. 38.4 minutes, P=0.00; 48.7 vs. 37.4 minutes, P=0.00; 48.3 vs. 36.6 minutes, P=0.00). Conclusions: The bench-surgery time takes longer in the PLDRH group regardless of reconstruction of type II or III portal vein variations and liver graft outflow or not.

Background: Anti-HBc positive donors represent an important source of organs in hepatitis B virus (HBV) endemic areas despite the risk of occult HBV infection. We analyzed long-term outcome of prevention for de novo HBV with hepatitis B immunoglobulin (HBIG) only after liver transplantation (LT) using core-positive grafts. Methods: We retrospectively reviewed the prospective collected data of 1,479 recipients between 1988 and 2018 at Seoul Nation al University Hospital. 1,458 were eligible and enrolled. If either donor or recipient had core antibody, HBIG 4000 IU was adminis trated 4 times until postoperative day 3. Results: Of 1,458 LTs, 478 (32.8%) used anti-HBc positive grafts. Three hundred twenty-six (68.2%) was allocated to hepatitis B surface antigen (HBsAg)-positive recipients, with 152 (31.8%) to HBs-negative recipients. 21 (13.8%) of de novo HBV infection occurred in 152 core-positive grafts. One (25%), 11 (22.4%), 0, 9 (9.2%) was diagnosed of de novo HBV infection in 4 of hepatitis B surface antigen (HBcAb) and HBsAb negative, 49 of HBcAb-negative and HBsAb-positive, 1 of HBcAb-positive and HBsAb-neg ative, 98 of HBcAb and HBsAb positive recipients respectively. Anti-HBc negative recipients were more likely to develop de novo HBV infection compared with anti-HBc positive recipients (22.6% vs. 9.1%, P=0.021). Incidence of de novo HBV infection did not differ by recipient HBsAb status (P=0.530). The median follow-up time was 69 months (range, 29-165 months). The median time to detection of HBsAg seropositivity was 18 months (range, 8-55 months). Two had no treatment, twelve were treated with nu cleoside analogs (NA) monotherapy, and seven were treated with NA plus HBIG. The median treatment duration was 41 months. Seven acquired seroconversion. There were 42 (8.8%) of graft losses in study period. The 1-, 5-, 10-year patient survival with an ti-HBc positive liver were 97.5%, 93.2%, and 90.5%. No patient died of de novo HBV infection. Conclusions: De novo HBV did not affect patient survival. However, HBIG only prophylaxis was not enough to prevent de novo HBV development in the era of NA.

Background: This retrospective study aimed to evaluate overall survival and the risk factors for mortality among Korean pediatric liver transplantation (LT) patients using data from two national registries: the Korean Network Organ Sharing (KONOS) of the Korea Centers for Disease Control and Prevention and the Korean Organ Transplantation Registry (KOTRY). Methods: Prospectively collected data of 755 pediatric patients who underwent primary LT (KONOS, February 2000 to December 2015, KOTRY, May 2014 to December 2017) were retrospectively reviewed. Results: The 1-, 5-, 10-, and 15-year survival rates were 90.6%, 86.7%, 85.8%, and 85.5%, respectively, in KONOS, and the 1-month, 3-month, 1-year, and 2-year survival rates were 92.1%, 89.4%, 89.4%, and 87.2%, respectively, in KOTRY. There was no significant difference in survival between the two registries. Multivariate analysis identified that body weight &ge, 6 kg (p &lt, 0.001), biliary atresia as underlying liver disease (p = 0.001), and high-volume center (p &lt, 0.001) were associated with better survival according to the KONOS database, while hepatic artery complication (p &lt, 0.001) was associated with poorer overall survival rates according to the KOTRY database. Conclusion: Long-term pediatric patient survival after LT was satisfactory in this Korean national registry analysis. However, children with risk factors for poor outcomes should be carefully managed after LT.

Studies on effective immunosuppressive strategies for the management of patients undergoing a liver transplantation (LT) due to hepatocellular carcinoma (HCC) are limited. In the present study, immunosuppressive candidates predicted to exhibit beneficial immunosuppressive and tumor-suppressive effects in patients with HCC were assessed using Huh7 and HEP3B HCC cells, which have high proportions of CD133+EpCAM+ cancer stem cell (CSC) populations. The immunosuppressants assessed were sirolimus, tacrolimus, cyclosporine A and mycophenolate mofetil (MMF), and their activities were assessed on CSCs. Sirolimus and MMF reduced the proliferation of Huh7 and HEP3B cells; however, the proportion of CD133+EpCAM+ was notably increased in treated Huh7 cells. Sirolimus treatment alone resulted in G0-G1 cell cycle arrest at all doses in all Huh7 and CD133-EpCAM- populations; however, CD133+EpCAM+ populations showed only slight G1 arrest at higher doses only. In contrast, S-phase arrest was induced at all doses in the Huh7, CD133-EpCAM- and CD133+EpCAM+ populations by MMF. Sirolimus and MMF effectively reduced the proliferation of Huh7 and HEP3B cells, but did not exert a notable effect on the CD133+EpCAM+ cells. Therefore, therapeutic strategies utilizing Sirolimus and MMF should be further studied in vivo for regulation of CSC populations in order to reduce HCC recurrence rates.

Cytochrome P450 (CYP) 3A5 polymorphism influences tacrolimus metabolism, but its effect on the drug pharmacokinetics in liver transplant recipients switched to once-daily extended-release formulation remains unknown. The aim of this study is to analyze the effect of CYP3A5 polymorphism on liver function after once-daily tacrolimus conversion in liver transplant patients. A prospective open-label study included 60 stable liver transplant recipients who underwent 1:1 conversion from twice-daily tacrolimus to once-daily tacrolimus. All participants were genotyped for CYP3A5 polymorphism. The study was registered at ClinicalTrials.gov (NCT 02882113). Twenty-eight patients were enrolled in the CYP3A5 expressor group and 32 in the non-expressor group. Although there was no statistical difference, incidence of liver dysfunction was higher in the expressor group than in the non-expressor group when converted to once-daily extended-release tacrolimus (p = 0.088). No biopsy-proven acute rejection, graft failure, and mortality were observed in either group. The decrease in dose-adjusted trough level (&minus, 42.9% vs. &minus, 26.1%) and dose/kg-adjusted trough level of tacrolimus (&minus, 40.0% vs. &minus, 23.7%) was significantly greater in the expressor group than in the non-expressors after the conversion. A pharmacokinetic analysis was performed in 10 patients and tacrolimus absorption in the non-expressor group was slower than in the expressor group. In line with this observation, the area under the curve for once-daily tacrolimus correlated with trough level (Cmin) in the non-expressors and peak concentration (Cmax) in the expressors. CYP3A5 genotyping in liver transplant recipients leads to prediction of pharmacokinetics after switching from a twice-daily regimen to a once-daily dosage form, which makes it possible to establish an appropriate dose of tacrolimus.

Backgrounds/aims Acute appendicitis is one of the most common emergent disease in the general population requiring surgical treatment. However, only a few cases of appendicitis after liver transplantation (LT) were reported. We described experiences of acute appendicitis after LT in single center. Methods From March 1988 to July 2019, we reviewed retrospectively all the patients who diagnosed with acute appendicitis after LT at the Seoul National University Hospital. We described and analyzed clinical outcomes of appendectomy after LT. Results A total of 12 patients out of 2,237 LT patients underwent appendectomy due to acute appendicitis. The mean age was 48±12 years. Nine patients (75%) underwent deceased donor liver transplantation (DDLT) and three patients (25%) underwent living donor liver transplantation (LDLT). The mean days from transplantation to the onset of acute appendicitis was 739 (range 57-4,496) days. Every patients underwent appropriate appendectomy within 1 days after visiting hospital. Leukocytosis was seen in three patients (25%). Seven patients (58%) underwent laparoscopic appendectomy and five patients (42%) underwent open appendectomy. The total operative time was 47.5 (range 25-135) minutes. The median postoperative hospitalization was 4 (range 2-11) days. There was no postoperative complications documented. There was no significant difference of clinical outcomes between laparoscopic appendectomy group and open appendectomy group. Conclusions Early surgical management achieved satisfactory postoperative results without graft dysfunction after LT. Laparoscopic appendectomy also could be applicable with safe and feasible outcomes even in post-LT recipients.

The survival outcomes of recurrent hepatocellular carcinoma (HCC) after curative resection remain unclear due to lack of clear basis for the selection of treatment option. We investigated overall survival (OS) after intrahepatic recurrence and re-recurrence free survival (rRFS) of the patients with recurrent HCC, and whether Milan criteria (MC) status at resection and recurrence impacts on OS and rRFS.We enrolled 959 patients who experienced recurrence after primary hepatic resection for HCC. We divided the cohort into four groups according to MC at two periods: IN-rIN MC (HCC within MC at the time of resection-recurrence within MC), IN-rOUT MC (HCC within MC at the time of resection-recurrence outside MC), OUT-rIN MC (HCC outside MC at the time of resection-recurrence within MC), and OUT-rOUT MC (HCC outside MC at the time of resection-recurrence outside MC).In the entire cohort, 1-, 3-, and 5-year OS after recurrence was 81.0%, 55.7%, and 45.8%, respectively, while rRFS was 63.7%, 46.1%, and 42.0%, respectively. The IN-rIN MC group had the best outcomes (5-year OS and rRFS, 54.5% and 45.7%, respectively). The IN-rOUT and OUT-rIN MC groups had better 5-year OS outcomes than the OUT-rOUT MC group (46.5%, 38.6%, and 24.8%, respectively; P 0.05). However, 5-year rRFS did not differ among the three groups (37.5%, 36.6%, and 31.9%, respectively; P 0.05).Survival after first recurrence following curative primary resection for HCC was affected by MC at both time of resection and recurrence. Both the IN-rOUT and OUT-rIN MC groups with similar survival outcomes can be saved via curative treatment.

The effect of preformed donor-specific antibodies (DSAs) on liver transplantation (LT) remains unclear, especially in the field of living donor LT (LDLT). Herein, we evaluated the prevalence of preformed DSAs and their effect on graft outcome in LDLT in the first year following surgery. Using the Luminex® Single Antigen assay, we analyzed the preoperative sera of 61 adult LDLT recipients between 2014 and 2015. Clinical outcomes and pathologic findings including complement component 4d (C4d) expression in the first year after LT were retrospectively reviewed. Regardless of the class of DSA, DSAs with mean fluorescence intensity (MFI) ≥1000 were defined as positive and preformed DSA with MFI ≥5000 was defined as strongly positive. Fifteen patients (24.6%) had preformed DSAs, and 8 patients (13.1%) showed strongly positive preformed DSAs. Among 15 DSA positive patients, 2 (13.3%) showed persistent DSAs after LDLT. No de novo DSAs were noted in patients without preformed DSAs. Preformed DSAs were not related to graft dysfunction, laboratory values, or C4d expression or other pathologic findings in the first year of LDLT. In conclusion, preformed DSAs persisted during follow-up in 13.3% of cases and did not have adverse effect on histologic or clinical outcomes in the first year of LDLT.

Pure laparoscopic donor hepatectomy, including right hepatectomy, is being increasingly performed at experienced centers (Kim et al. Transplantation 101:1106-1110, 2017; Han et al. Medicine (Baltimore) 96:e8076, 2017; Suh et al. Am J Transplant 18:434-443, 2018; Hong et al. Br J Surg 105:751-759, 2018; Lee et al. Transplantation 102:1878-1884, 2018). However, anatomical variations in the portal vein remain major challenges and are regarded as contraindications by some centers. Using a stapler or clip in donors with these anatomical variations may result in kinking of the remnant portal vein due to the thick linear bite, as well as a reduction in the length of the graft portal vein. This report describes a liver donor with separate right posterior and anterior portal veins who underwent pure 3D laparoscopic donor right hepatectomy, focusing on a new technique of managing separate two portal veins.A 45-year-old man offered to donate part of his liver to his father, who required a liver transplant for alcoholic liver cirrhosis. The father's Child-Pugh score was 7 and his Model for End-Stage Liver Disease score was 10.7. Donor height was 175.4 cm, body weight was 79.9 kg, and body mass index was 26.0 kg/mThe total operation time was 365 min, with no transfusion and no intraoperative complications. The portal veins were divided safely without any torsion or stricture. The stumps of the portal veins were sutured after retrieval of the liver graft, with suturing requiring about 12 min. The donor was discharged on postoperative day 7 with no complications.The SNUH technique, consisting of temporary clipping, intracorporeal suturing, and clip removal is safe and useful for pure laparoscopic right hepatectomy in donors with anatomic variations in the portal vein.

Split-liver transplantation (SLT) should be cautiously considered because the right trisection (RTS) graft can be a marginal graft in adult recipients. Herein, we analyzed the outcomes of RTS-SLT in Korea, where75% of adult liver transplantations are performed with living donor liver transplantation. Among 2462 patients who underwent deceased donor liver transplantations (DDLTs) from 2005 to 2014, we retrospectively reviewed 86 (3.5%) adult patients who received a RTS graft (RTS-SLT group). The outcomes of the RTS-SLT group were compared with those of 303 recipients of whole liver (WL; WL-DDLT group). Recipient age, laboratory Model for End-Stage-Liver Disease (L-MELD) score, ischemia time, and donor-to-recipient weight ratio (DRWR) were not different between the 2 groups (P0.05). However, malignancy was uncommon (4.7% versus 36.3%), and the donor was younger (25.2 versus 42.7 years) in the RST-SLT group than in the WL-DDLT group (P0.05). The technical complication rates and the 5-year graft survival rates (89.0% versus 92.8%) were not different between the 2 groups (P0.05). The 5-year overall survival (OS) rate (63.1%) and graft-failure-free survival rate (63.1%) of the RTS-SLT group were worse than that of the WL-DDLT group (79.3% and 79.3%; P0.05). The factors affecting graft survival rates were not definite. However, the factors affecting OS in the RTS-SLT group were L-MELD score30 and DRWR ≤1.0. In the subgroup analysis, OS was not different between the 2 groups if the DRWR was1.0, regardless of the L-MELD score (P0.05). In conclusion, a sufficient volume of the graft estimated from DRWR-matching could lead to better outcomes of adult SLTs with a RTS graft, even in patients with high L-MELD scores.

Liver transplantation (LT) is an excellent treatment option for patients with biliary atresia (BA) who fail portoenterostomy surgery. LT is also increasingly performed in patients with metabolic liver diseases. This study compared the outcomes in pediatric patients who underwent LT for metabolic liver diseases and BA.Data from 237 pediatric patients who underwent primary LT at Seoul National University Hospital from 1988 to 2015, including 33 with metabolic liver diseases and 135 with BA, were retrospectively analyzed.Compared with children with BA, children with metabolic liver diseases were significantly older at the time of LT (121.3 vs. 37.3 months; P 0.001), and had lower Child-Pugh (7.1 vs. 8.4; P = 0.010) and Pediatric End-stage Liver Disease (6.5 vs. 12.8; P = 0.042) scores. Overall survival rates were similar (87.8% vs. 90.8%; P = 0.402), but hepatic artery (HA) complications were significantly more frequent in children with metabolic liver diseases (12.1% vs. 1.5%; P = 0.014).Despite similar overall survival, children with metabolic liver diseases had a higher rate of HA complications.Original article, Case control study, Retrospective.III.

Improvements in laparoscopic imaging systems and instruments have increased the performance of pure laparoscopic living donor hepatectomy. This operation is no longer limited to left lateral sectionectomy but is used for left hepatectomy and right hepatectomy.1-5 This report describes a donor who underwent pure laparoscopic left lateral sectionectomy and in situ reduction using 3D laparoscopy and indocyanine green (ICG) near-infrared fluorescence cholangiography to obtain a monosegment. A 43-year-old woman offered to donate part of her liver to her daughter, who required a transplant for acute liver failure after a Kasai operation for biliary cirrhosis caused by biliary atresia. Donor height was 150.4 cm, body weight was 56.8 kg, and body mass index was 25.1 kg/m2. Liver dynamic CT showed a left lateral liver volume of 223 cm3, and an estimated graft-to-recipient weight ratio (GRWR) of 4.4%. The entire procedure including in situ reduction was performed under 3D laparoscopic view. The optimal bile duct division point was determined by real time ICG fluorescence cholangiography. The total operation time was 320 min, with no transfusion required and no intraoperative complications. Intraoperative real time ICG fluorescence cholangiography revealed the donor’s bile duct anatomy and identified the optimal division point. The final graft weighed 167 g, 48 g being reduced in situ, with a GRWR of 3.3%. The donor was discharged on postoperative day 8 with no complications. Pure 3D laparoscopic left lateral sectionectomy and in situ reduction are feasible for obtaining a donor monosegment for pediatric living donor liver transplantation.