Salvage living donor liver transplantation versus repeat liver resection for patients with recurrent hepatocellular carcinoma and Child-Pugh class A liver cirrhosis: A propensity score-matched comparison.

Following curative liver resection (LR), resectable tumor recurrence in patients with preserved liver function leads to deciding between a repeat LR and a salvage liver transplantation (LT), if a donor's liver is available. This retrospective study compared survival outcomes and recurrence pattern following salvage living donor LT (LDLT) and repeat LR in patients with recurrent hepatocellular carcinoma (HCC). We reviewed the medical records of patients who underwent repeat LR (n = 163) or LDLT (n = 84) for recurrent HCC following curative resections, between January 2005 and December 2017 at a single institution. A 1:1 propensity score matching led to 42 patients per group. Disease-specific and recurrence-free survival were significantly better in the salvage LDLT group than in the repeat LR group (p = .042; HR = 2.40; 95% CI, 0.69-6.00 and p < .001; HR = 4.23; 95% CI, 2.05-8.71, respectively). Despite significant differences in recurrence patterns between the two groups (p = .019), the patient death rates, after recurrence, were similar for both groups (p = .760). This study indicates that salvage LDLT is superior to repeat LR for treating patients with transplantable, intrahepatic HCC recurrence, even in patients with Child-Pugh class A liver cirrhosis.

Long-Term Safety and Efficacy of Pure Laparoscopic Donor Hepatectomy in Pediatric Living Donor Liver Transplantation.

Laparoscopic living donor hepatectomy for transplantation has been well established over the past decade. This study aimed to assess its safety and feasibility in pediatric living donor liver transplantation (LDLT) by comparing the surgical and long-term survival outcomes on both the donor and recipient sides between open and laparoscopic groups. The medical records of 100 patients (≤17 years old) who underwent ABO-compatible LDLT using a left lateral liver graft between May 2008 and June 2016 were analyzed. A total of 31 donors who underwent pure laparoscopic hepatectomy and their corresponding recipients were included in the study; 69 patients who underwent open living donor hepatectomy during the same period were included as a comparison group. To overcome bias from the different distributions of covariables among the patients in the 2 study groups, a 1:1 propensity score matching analysis was performed. The mean follow-up periods were 92.9 and 92.7 months in the open and laparoscopic groups, respectively. The mean postoperative hospital stay of the donors was significantly shorter in the laparoscopic group (8.1 days) than in the open group (10.6 days; P < 0.001). Overall, the surgical complications in the donors and overall survival rate of recipients did not differ between the groups. Our data suggest that the laparoscopic environment was not associated with long-term graft survival during pediatric LDLT. In addition, the laparoscopic approach for the donors did not adversely affect the corresponding recipient's outcome. Laparoscopic left lateral sectionectomy for living donors is a safe, feasible, and reproducible procedure for pediatric liver transplantation.

Validation of the prognostic performance in various nodal staging systems for gallbladder cancer: results of a multicenter study.

BACKGROUND: Although the current nodal staging system for gallbladder cancer (GBC) was changed based on the number of positive lymph nodes (PLN), it needs to be evaluated in various situations. METHODS: We reviewed the clinical data for 398 patients with resected GBC and compared nodal staging systems based on the number of PLNs, the positive/retrieved LN ratio (LNR), and the log odds of positive LN (LODDS). Prognostic performance was evaluated using the C-index. RESULTS: Subgroups were formed on the basis of an restricted cubic spline plot as follows: PLN 3 (PLN = 0, 1-2, ≥ 3); PLN 4 (PLN = 0, 1-3, ≥ 4); LNR (LNR = 0, 0-0.269, ≥ 0.27); and LODDS (LODDS < - 0.8, - 0.8-0, ≥ 0). The oncological outcome differed significantly between subgroups in each system. In all patients with GBC, PLN 4 (C-index 0.730) and PLN 3 (C-index 0.734) were the best prognostic discriminators of survival and recurrence, respectively. However, for retrieved LN (RLN) ≥ 6, LODDS was the best discriminator for survival (C-index 0.852). CONCLUSION: The nodal staging system based on PLN was the optimal prognostic discriminator in patients with RLN < 6, whereas the LODDS system is adequate for RLN ≥ 6. The following nodal staging system considers applying different systems according to the RLN.

A nationwide study of regional preference and graft survival of kidney transplantation in South Korea: patterns of centralization in the capital area.

Purpose: This study aims to investigate regional patterns and graft survival rates in kidney transplantation (KT) within South Korea using the National Health Insurance Service database. Methods: By analyzing KT data from 2002 to 2017, including patient residency, KT location, and post-KT dialysis information, graft survival was assessed through post-KT dialysis and validated against Ulsan University Hospital and the Korean Organ Transplantation Registry's 2017 report. Results: Among the 20,978 KTs, 60.5% occurred in the Korean capital, Seoul, whereas 39.5% occurred outside. The overall graft survival rate was 81.5% with a median survival duration of 57 months. Patient survival was 83.8%, with a median survival duration of 61 months. For KTs from 2002 to 2007, the 10-year graft and patient survival rates were 89.1% and 90.3%, respectively. The KT recipients living outside Seoul who underwent the KT within their residential regions had a graft survival rate of 88.3%, and those receiving KTs outside their original region had a graft survival rate of 88.0%. Among Seoul residents who underwent KTs in the city, the graft survival rate was 90.5%. Importantly, hospital location did not significantly affect graft survival rates (P = 0.136). Conclusion: This study revealed a regional preference for KT in South Korea, particularly in the capital city, likely because of nonresidents. Nevertheless, the graft and patient survival rates showed no significant regional disparities. These findings emphasize the necessity for equitable KT service access across regions in order to optimize patient outcomes.

Highly parallel and ultra-low-power probabilistic reasoning with programmable gaussian-like memory transistors.

Probabilistic inference in data-driven models is promising for predicting outputs and associated confidence levels, alleviating risks arising from overconfidence. However, implementing complex computations with minimal devices still remains challenging. Here, utilizing a heterojunction of p- and n-type semiconductors coupled with separate floating-gate configuration, a Gaussian-like memory transistor is proposed, where a programmable Gaussian-like current-voltage response is achieved within a single device. A separate floating-gate structure allows for exquisite control of the Gaussian-like current output to a significant extent through simple programming, with an over 10000 s retention performance and mechanical flexibility. This enables physical evaluation of complex distribution functions with the simplified circuit design and higher parallelism. Successful implementation for localization and obstacle avoidance tasks is demonstrated using Gaussian-like curves produced from Gaussian-like memory transistor. With its ultralow-power consumption, simplified design, and programmable Gaussian-like outputs, our 3-terminal Gaussian-like memory transistor holds potential as a hardware platform for probabilistic inference computing.

The feasibility and safety of a three-port laparoscopic cholecystectomy using a 2mm mini-instrument.

BACKGROUND/AIMS: The aim of this study was to show that this technique is feasible, safe and easily reproducible and to evaluate the selection criteria for a three-port laparoscopic cholecystectomy using a 2 mm mini-port (M-LC). METHODOLOGY: Prospectively collected data from 133 patients who underwent LC for benign gallbladder disease were retrospectively reviewed. The patient's selection for M-LC was determined by the surgeon's judgment based on 'laparoscopic surgical view' after inserting the laparoscope in the operating room. RESULTS: Seventy (52.6%) underwent M-LC (11 mm, 5 mm and 2 mm) and 63 patients with complicated gallbladder disease underwent conventional three-port LC (C-LC) (11 mm, 5 mm and 5 mm). Elective LC was performed in 77 of the 133 patients, and M-LC was conducted in 70 (90.9%) of 77 patients with symptomatic uncomplicated cholelithiasis or gallbladder polyps. There were no significant surgically related complications in both groups (p=0.28). No patients in the M-LC group required a conversion to an open cholecystectomy, but one case in the M-LC group required an additional port (5 mm) because of cystic artery bleeding. CONCLUSIONS: M-LC is a feasible, safe and nearly scarless procedure in the patients with uncomplicated gallbladder disease.

The novel use and feasibility of hemostatic oxidized regenerated cellulose agent (SurgiGuard®): multicenter retrospective study.

Background: SurgiGuard® is an absorbent hemostatic agent based on oxidized regenerated cellulose. The efficacy, effects and safety of SurgiGuard® are equivalent to existing hemostatic agents in animal experiments. This study was designed to confirm that the use of SurgiGuard® alone is effective, safe and feasible compared to combination with other hemostatic methods. Methods: We retrospectively reviewed clinical data from 12 surgery departments in seven tertiary centers in South Korea nationwide. All surgeries were performed between January and December 2018. Results: A total of 807 patients were enrolled; 447 patients (55.4%) had comorbidities. The rate of major surgery (operative time ≥4 hours) was 44% (n=355 patients). Regarding the type of SurgiGuard® used in surgery, more than 70% of minor surgeries used non-woven types. In major surgery, more than five SurgiGuards® were used in 7.3% (26 patients), and the proportion of co-usage (with four other hemostatic products) was 19.7% (70 patients). The effectiveness score was higher when SurgiGuard® was used alone in both major (5.3±0.5 vs. 5.1±0.6, P=0.048) and minor surgery (5.4±0.6 vs. 5.2±0.4, P<0.001). Seven patients had immediate re-bleeding, and all of them used SurgiGuard® and other products together. Nine patients reported adverse effects, such as abscess, bleeding, or leg swelling, but we found no direct correlation with SurgiGuard®. Conclusions: SurgiGuard® exhibited greater effectiveness when used alone. No direct adverse effects associated with SurgiGuard® use were reported, and SurgiGuard® had stable feasibility. Prospective comparative studies are needed in the future.

A Multicenter, Randomized, Open-Label Study to Compare the Efficacy and Safety of Tacrolimus and Corticosteroids in Combination With or Without Mycophenolate Mofetil in Liver Transplantation Recipients Infected With Hepatitis B Virus.

BACKGROUND: Mycophenolate mofetil exhibits pharmacologic mechanisms different from calcineurin inhibitors. Therefore, the dose of calcineurin inhibitors can be reduced along with side effects for effective immunosuppression. We aimed to evaluate the efficacy and safety of tacrolimus and corticosteroid in combination with or without mycophenolate mofetil in living donor liver transplantation (LDLT) recipients infected with hepatitis B virus (HBV). METHODS: A randomized, open-label, comparative, multicenter, phase IV study was conducted with 119 patients from January 2014 to September 2017. In the full analysis set population, 58 and 59 patients were included in the study group (triple-drug regimen: TacroBell + My-rept + corticosteroid) and the control group (dual-drug regimen: TacroBell + corticosteroid), respectively. In the per protocol set population, 49 and 42 patients were included in the study and control groups, respectively. RESULTS: In the full analysis set population, the incidence of biopsy-proven acute cellular rejection (rejection activity index score ≥4) was 3.4% in the study group; however, this finding was not observed in the control group (P = .468). Hepatitis B virus recurrence was observed in one patient in the control group. No cases of biopsy-proven acute cellular rejection and HBV recurrence were observed in the per protocol set population. The incidences of serious adverse events were 25.9% and 18.0% in the study and control groups, respectively; however, the difference between the groups was not statistically significant (P = .376). CONCLUSION: Although the study involved a small number of patients, the triple-drug regimen can be considered safe and effective for immunosuppression after living donor liver transplantation in patients infected with HBV.

Mini-incision Right Hepatectomy for Living Donor Hepatectomy.

BACKGROUND: The application of a minimally invasive technique to graft procurement in living donor liver transplantation has minimized skin incisions and led to early recovery in donor hepatectomy while ensuring donor safety. This study aimed to evaluate the safety and feasibility of mini-incision living donor right hepatectomy compared with conventional open surgery. METHODS: The study population consisted of 448 consecutive living donors who underwent living donor right hepatectomy performed by a single surgeon between January 2015 and December 2019. According to the incision type, the donors were divided into 2 groups: a right subcostal mini-incision group (M group: n = 187) and a conventional J-shaped incision group (C group: n = 261). A propensity score matching analysis was conducted to overcome bias. RESULTS: The estimated graft volume and measured graft weight were significantly lower in the M group ( P = 0.000). The total of 17 (3.8%) postoperative complications were identified. The readmission rate and overall postoperative complication rate of donors was not significantly different between the groups. The biliary complication rates in the recipients were 12.6% and 8.6% in the C group and M group, respectively ( P = 0.219). Hepatic artery thrombosis requiring revision developed in 2 patients (0.8%) in the C group and 7 patients (3.7%) in the M group ( P = 0.038). After propensity score matching, these complications were not significantly different between the groups. CONCLUSIONS: Mini-incision living donor right hepatectomy shows comparable biliary complications to open surgery and is considered a safe and feasible operative technique.

Comparison of infectious complications after spleen preservation versus splenectomy during laparoscopic distal pancreatectomy for benign or low-grade malignant pancreatic tumors: A multicenter, propensity score-matched analysis.

BACKGROUND: Previous studies have reported contrasting results regarding the advantages of spleen preservation during laparoscopic distal pancreatectomy (LDP) for preventing infectious complications. METHODS: A total of 3787 patients who underwent LDP for benign or low-grade malignant pancreatic disease in 92 centers across Korea and Japan were included in this retrospective study. Postoperative infectious complications and other complications were compared between LDP with splenectomy (LDPS) and LDP with spleen preservation (LSPDP) by propensity score matching (PSM) analysis. RESULTS: After PSM, the LSPDP group had a lower rate of overall infectious complications (P = .079) and a significantly lower rate of intra-abdominal abscess (P = .014) compared with the LDPS group. Within the LSPDP group, the vessel preservation subgroup had a significantly higher rate of infectious complications (P = .002) compared with the vessel resection subgroup. Low-volume centers had a higher rate of intra-abdominal abscess than high-volume centers in the LSPDP group (P = .001) and the splenic vessel preservation subgroup (P = .003). CONCLUSIONS: Spleen preservation in LDP for benign or borderline malignant pancreatic diseases was advantageous in lowering the risk of infectious complications, specifically intra-abdominal abscess. However, the risk of intra-abdominal abscess may differ according to the level of surgeon's experience.

Squamoid cyst of pancreatic ducts: A case report.

The term squamoid cyst of pancreatic ducts (SCOP) has been proposed recently, and it is a very rare benign lesion. We report a case of SCOP in a patient who underwent laparoscopic distal pancreatectomy. A 51-year-old woman presented with a pancreatic cystic lesion (3.3 cm) as an incidental finding on abdominal ultrasonography. A computed tomography scan showed a well-defined cystic lesion in the body of the pancreas with peripheral nodular calcification. Histology showed a unilocular cyst with a thin, fibrotic wall, and it was surrounded by normal-appearing pancreatic tissue. The lining of the cyst was composed of stratified non-keratinized squamous epithelium without significant nuclear atypia. Immunohistochemistry showed positive nuclear p63 expression in the cyst lining. The final diagnosis of SCOP was established. It is important to distinguish SCOPs from mucinous pancreatic cysts that have malignant potential. Preoperative diagnosis of SCOP is still difficult, and further studies are needed to identify specific preoperative characteristics that can accurately distinguish this lesion.

Microsurgical Hepatic Artery Reconstruction in Deceased Donor Liver Transplantation for Reduced Arterial Complications.

Aberrant donor hepatic artery anatomy or hepatic artery injury during organ procurement or recipient preparation poses a surgical challenge during deceased donor liver transplantation. In this study, we aimed to investigate arterial reconstruction using microvascular techniques during deceased donor liver transplantation and suggest reasonable indications for the microsurgical approach in this setting. We retrospectively reviewed the outcomes of 470 deceased donor liver transplantations performed at our institution between July 2011 and December 2015. Of these, 128 recipients underwent microsurgical hepatic artery reconstruction and 342 underwent reconstruction with surgical loupes. Thirty-two patients (6.8%) experienced hepatic artery-related complications, including hepatic artery thrombosis (n = 8, 1.7%). In the propensity score-matched cohort, the surgical loupe group showed a higher complication rate (P = .782). On multivariate analysis, cold ischemia time (odds ratio, 0.995; 95% confidence interval, 0.9920-0.999; P = .009) and use of aortohepatic conduits (odds ratio, 5.254; 95% confidence interval, 1.878-14.699; P = .002) were independent predictors of arterial complications. The low incidence of hepatic artery complications in this study is likely attributable to the active application of microsurgical techniques. Active application of back-table microsurgical plasty and selective application of microsurgical techniques for main arterial reconstruction may help minimize operative difficulties and arterial complications.

Ruptured Hemorrhagic Ectopic Pregnancy Implanted in the Diaphragm: A Rare Case Report and Brief Literature Review.

The mortality and morbidity rates of non-tubal ectopic pregnancies with abdominal hemorrhaging are 7-8 times higher than those of tubal pregnancies. Diaphragmatic pregnancy is a rare non-tubal ectopic form, causing acute abdominal hemoperitoneum. Here, we present a case of a primary diaphragmatic ectopic pregnancy with hemorrhage that was immediately diagnosed and successfully managed with laparoscopic surgery. Rapid and accurate diagnosis using appropriate imaging modalities is critical for improving the prognosis of a child-bearing woman with an abdominal pregnancy.

Single-Center Experience of Living Donor Liver Transplantation for Patients With Secondary Biliary Cirrhosis.

BACKGROUND: Secondary biliary cirrhosis (SBC) represents a unique form of cirrhosis that develops in the liver secondary to persistent biliary obstruction. This study aimed to review the living donor liver transplants (LDLTs) performed at our center for patients with SBC and end-stage liver disease and to share the perioperative strategies undertaken to achieve satisfactory outcomes. METHODS: The medical records of 29 patients who underwent LDLT for SBC between December 1994 and July 2018 at the Asan Medical Center (Seoul, South Korea) were retrospectively reviewed. Their clinical data were extracted and statistically analyzed. Survival curves were computed. RESULTS: The perioperative and in-hospital morbidity rates were 72.4% and 10.3%, respectively. The overall mean recipient follow-up was 80.0 (SD, 66.4) months (range, 0.8-246.8 months). Patient survival rates after 1, 3, 5, and 10 years after transplant were 82.8%, 79.3%, 79.3%, and 79.3%, respectively. For liver grafts, the survival rates were 82.8%, 75.8%, 75.8%, and 75.8% at 1, 3, 5, and 10 years, respectively. CONCLUSIONS: LDLT is potentially a final lifesaving resort for patients with SBC with portal hypertension. However, considering the difficulty of surgery and perioperative management, LDLT should be performed by experienced transplant surgeons in a center where a multidisciplinary approach is possible.

Right lobe estimated blood-free weight for living donor liver transplantation: accuracy of automated blood-free CT volumetry--preliminary results.

PURPOSE: To determine the relative accuracy of automated blood-free to blood-filled computed tomographic (CT) volumetry for estimation of right-lobe weight in living donor liver transplantation. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board; informed consent was waived. Between October 1, 2008, and April 30, 2009, 88 live liver donors (54 men, 34 women; mean age, 26.1 years +/- 6.9 [standard deviation]) who underwent CT and had their right lobes procured in the study institution were included. Automated measurement of blood-filled volume (V(BFill)) and blood-free volume (V(BFree)) of the right lobe was performed by using 16-row multidetector CT performed with 5-mm intervals. Actual hepatic weight was measured blood free during surgery. Percentage blood volume, %V(B), was calculated as follows: %V(B) = V(BFill) - V(BFree)/V(BFill) . 100. Pearson tests were performed to determine correlation coefficients between V(BFill)/1.22 or V(BFree) and weight. Percentage deviation and percentage absolute deviation of V(BFree) from weight were compared with those of V(BFill)/1.22 by using a paired t test or Wilcoxon rank sum test. Regression analysis was performed between V(BFree) and weight. RESULTS: Mean V(BFill), V(BFree), and weight were 789.0 mL +/- 126.4, 713.9 mL +/- 114.4, and 717.8 g +/- 110.4. Percentage blood volume varied from 6.5% to 19.8% (mean, 9.5%). Compared with weight, the correlation coefficient was slightly higher with V(BFree) (r = 0.9140) than with V(BFill)/1.22 (r = 0.8909). Mean percentage deviation and percentage absolute deviation were significantly smaller with V(BFree) (-0.4% +/- 6.3, 5.0% +/- 3.8; P < .001) than with V(BFill)/1.22 (-9.8% +/- 6.5, 10.2% +/- 7.3; P < .001). The equation relating V(BFree) and weight, W, was as follows: W = (0.8815 . V(BFree)) + 88.5117, with R(2) of 0.8355 (P < .001). CONCLUSION: At automated CT volumetry in live liver donors, the percentage blood volume varies. The V(BFree) is more accurate than is V(BFill)/1.22 in estimation of hepatic weight.

Continuous peritransplant assessment of consciousness using bispectral index monitoring for patients with fulminant hepatic failure undergoing urgent liver transplantation.

BACKGROUND: Rapid deterioration of consciousness is a critical situation for patients with fulminant hepatic failure (FHF). Bispectral (BIS) index was derived from electroencephalography parameters, primarily to monitor the depth of unconsciousness. AIM: To assess the usability of peritransplant BIS monitoring in patients with FHF. METHODS: A prospective study using peritransplant BIS monitoring was performed in 26 patients with FHF undergoing urgent liver transplantation (LT). RESULTS: Pre-transplant Child-Pugh score was 12.2 +/- 1.0; model for end-stage liver disease score was 32.4 +/- 4.4; Glasgow coma score (GCS) was 9.9 +/- 1.3; and BIS index was 44.0 +/- 6.7. Pre-transplant sedation significantly decreased BIS index. After LT, all patients having endotracheal intubation recovered consciousness within one to three d and showed progressive increase in BIS index, which appeared slightly earlier and was more evident than the increase in derived GCS score. There was a significant correlation between BIS index and derived GCS scores (r(2) = 0.648). Timing of eye opening to voice was matched with BIS index of 66.3 +/- 10.4 and occurred 12.7 +/- 8.3 h after passing BIS index of 50. CONCLUSION: These results suggest that BIS monitoring is a non-invasive, simple, easy-to-interpret method, which is useful in assessing peritransplant state of consciousness. BIS monitoring may therefore be a useful tool during peritransplant intensive care for patients with FHF showing hepatic encephalopathy.

Clinical implication of tumor site in terms of node metastasis for intrahepatic cholangiocarcinoma.

BACKGROUND: The clinical implication of lymph node (LN) dissection of intrahepatic cholangiocarcinoma (ICCA) is still controversial, and LN metastasis (LNM) based on tumor site has not been confirmed yet. METHODS: Patients who underwent curative-intent surgery at 10 tertiary referral centers were identified and divided into peripheral (PP) and near second confluence level tumor (NC) groups on the basis of the distance from the second confluence and oncological outcomes were compared. RESULTS: Of 179 patients, 121 patients with LND were divided into the NC (n = 89) and PP groups (n = 32) on the basis of 4.5 cm from the second confluence. NC group showed higher LNM rate than PP group (46.1 vs 21.9%, p = 0.016) and NC was a risk factor for LNM (odds ratio: 4.367; 95% confidence interval: 1.234-15.453, p = 0.022). The 5-year overall survival (OS) rate (38.0% vs. 27.8%, p = 0.777) and recurrence-free survival (RFS) rates (22.8% vs. 25.8%, p = 0.742) showed no differences between the PP and NC groups. In the NC group, N1 patients showed worse 5-year OS (12.7% vs 39.0%, p = 0.004) and RFS (8.8% vs 28.6%, p = 0.004) than the N0 patients. In the PP group, discordant results in 5-year OS (48.9% vs. 50.0%, p = 0.462) and RFS (41.3% vs. 0%, p = 0.056) were found between the N0 and N1 patients. CONCLUSION: The NC group was an independent risk factor for LNM and LNM worsened prognosis in NC group for ICCA. In the PP group, LND should not be omitted because of high LNM rate and insufficient oncologic evidence.

Duodenal Penetration by the Ringed Expanded Polytetrafluoroethylene Graft for Middle Hepatic Vein Reconstruction During Living-Donor Liver Transplant: A Case Report.

Expanded polytetrafluoroethylene grafts are widely used for middle hepatic vein reconstruction during living-donor liver transplant because they have comparable patency to autologous or cryopreserved vessels. Mechanical complications like gastric or duodenal penetration by expanded polytetrafluoroethylene grafts have been infrequently reported. We recently experienced a case of duodenal penetration by the expanded polytetrafluoroethylene graft. The patient was a 57-year-old man who had undergone a living-donor liver transplant for cryptogenic liver cirrhosis. At an annual follow-up computed tomography scan performed 3 years after transplant, the expanded polytetrafluoroethylene graft appeared to have penetrated into the first to the second portion of the duodenum, and abnormal air shadow and partial thrombus were identified within the expanded polytetrafluoroethylene graft. The patient underwent exploratory laparotomy, the expanded polytetrafluoroethylene graft was removed, and the perforated duodenum was repaired. Pyloric exclusion with gastrojejunostomy and feeding jejunostomy was additionally performed because of a wide defect in the duodenum. Adjacent organ injuries such as duodenal or gastric penetration by the expanded polytetrafluoroethylene graft after living-donor liver transplant is rare but not uncommon. Because the use of expanded polytetrafluoroethylene grafts is essential when an adequate vessel allograft is unavailable, we can consider transposition of the omental flap between the expanded polytetrafluoroethylene graft and the stomach or duodenum to reduce this unexpected complication.

Highlights of the Third Expert Forum of Asia-Pacific Laparoscopic Hepatectomy; Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017.

The application of laparoscopy for liver surgery is rapidly increasing and the past few years have demonstrated a shift in paradigm with a trend towards more extended and complex resections. The development of instruments and technical refinements with the effective use of magnified caudal laparoscopic views have contributed to the ability to overcome the limitation of laparoscopic liver resection. The Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017 and the 3rd Expert Forum of Asia-Pacific Laparoscopic Hepatectomy organized hepatobiliary pancreatic sessions in order to exchange surgical tips and tricks and discuss the current status and future perspectives of laparoscopic hepatectomy. This report summarizes the oral presentations given at the 3rd Expert Forum of Asia-Pacific Laparoscopic Hepatectomy.

Retroduodenal resection of ampullary carcinoid tumor in a patient with cavernous transformation of the portal vein.

Although pancreatoduodenectomy is the standard treatment for periampullary neoplasms, limited pancreas-preserving resections are sometimes performed. This report describes a carcinoid tumor of the ampulla of Vater for which pancreatoduodenectomy was not feasible because of diffuse cavernous transformation of the portal vein (PV) secondary to main PV obliteration of unknown cause. We performed retroduodenal resection of the ampullary carcinoid with total preservation of the pancreas. The duodenal wall defect was primarily repaired, and the pancreatic and bile ducts were separately reconstructed using Roux-en-Y pancreaticojejunostomy and choledochojejunostomy. The patient recovered uneventfully and is currently progressing well at 10 months postoperatively, with no tumor recurrence or complications. The surgical procedures are described, and the literature pertaining to this limited surgery is reviewed.