[A Case of Long-Term Survival of a Patient with Liver Metastasis of Colon Cancer and Suspected Inferior Vena Cava Invasion].

A 58-year-old woman was diagnosed with a sigmoid colon cancer and synchronous liver metastasis. Because an obstruction of the sigmoid colon was identified, the patient underwent sigmoidectomy. Computed tomography(CT)findings suggested possible vena cava and hepatic vein invasion. Therefore, the decision was made to offer systemic chemotherapy. The patient underwent 6 courses of chemotherapy with 5-fluorouracil, Leucovorin, and oxaliplatin (mFOLFOX6). After 4 courses of chemotherapy, CT scans showed a significant reduction of the liver metastasis (reduction rate of 5 0%; a partial response) and demonstrated improved exclusion of the inferior vena cava and hepatic vein. After 6 courses of chemotherapy, we performed right trisegmentectomy of the liver and resection of the inferior vena cava and diaphragm. Postoperative pathological findings revealed negative margins, and no invasion of the inferior vena cava. The pathological response grade of the tumor after chemotherapy was determined to be Grade 2. Adjuvant chemotherapy was not performed because of the patient 's poor performance status. The patient was alive with no recurrence 8 years after resection of the liver metastasis.

Esophagectomy and pancreatoduodenectomy in the same patient: tactical and technical considerations.

Esophagectomy (EE) and pancreatoduodenectomy (PDE) are considered the most invasive and technically demanding surgical procedures performed on the digestive organs. These surgical interventions significantly change the normal anatomic relationships in the upper abdomen. Any additional digestive surgeries, especially resectional procedures, performed after a prior EE or PDE can be extremely difficult. The cases of simultaneous or metachronous EE and PDE in the same patient are very interesting from both a scientific and a practical viewpoint. We collected and analyzed the existing literature data on EE and PDE in the same patient. There were 60 cases: 3 cases of EE after PDE, 22 cases of PDE after EE, and 35 cases of simultaneous EE and PDE. The technical and tactical features of the surgery in a different sequence of stages or in a simultaneous procedure are discussed in a review.

Portal vein infusion chemotherapy with gemcitabine after surgery for pancreatic cancer.

PURPOSES: Pancreatic cancer still has a poor prognosis even after curative resection because of the high incidence of postoperative liver metastasis. This study prospectively evaluated the feasibility and tolerability of portal vein infusion chemotherapy of gemcitabine (PVIG) as an adjuvant setting after pancreatic resection. METHODS: Thirteen patients enrolled in this study received postoperative chemotherapy with PVIG. The patients received intermittent administration of gemcitabine (800 mg/m(2)) via the portal vein on days 1, 8, and 15 after surgery. The tolerability and the toxicity of PVIG were closely monitored. RESULTS: The PVIG was started on an average of 3.1 days after surgery. Complete doses of chemotherapy (three sessions of portal infusion) were accomplished in 11 of the 13 patients. Grade 3 or 4 leukocytopenia was observed in three patients (23 %), and liver dysfunction was found in one patient (7.7 %). Grade 2 sepsis developed in two cases due to bloodstream infection. Liver metastasis was the first site of recurrence in only two patients. CONCLUSIONS: PVIG can be administered to the liver with acceptable toxicity, but myelosuppression is similar to the systemic use of gemcitabine. Careful observation is required even for locoregional chemotherapy.

Hepatic resection for liver metastases from carcinomas of the distal bile duct and of the papilla of Vater.

PURPOSE: Hepatectomy for liver metastasis from carcinomas of the distal bile duct (BDC) and of the papilla of Vater (PVC) has not been studied in detail. The purpose of this study is to analyze risk factors of liver metastasis and to evaluate outcome of hepatectomy for liver metastasis. METHODS: Risk factors of liver metastasis were analyzed in 122 patients who underwent pancreaticoduodenectomy for BDC or PVC. In addition, 13 patients who underwent hepatectomy were reviewed. RESULTS: Liver metastasis after pancreaticoduodenectomy occurred in 33.8% of BDC and 26.3% of PVC patients. Multivariate analyses revealed that microvenous invasion was a significant risk factor common to BDC and PVC (p ≤ 0.05). However, 4 of the 13 resected cases survived more than 5 years (5-year survival rate, 44.9%). All four long-term survivors underwent margin-negative hepatectomy for a solitary metastasis and were given postoperative adjuvant chemotherapy. Margin-positive hepatectomy in four patients resulted in early re-recurrence of tumor. Limited hepatectomy (three cases) provided margin-positive surgery. CONCLUSIONS: Hepatectomy for a solitary metastasis is the treatment of choice even after pancreaticoduodenectomy, but indication of hepatectomy for multiple metastases is still limited. The combination of surgery and adjuvant chemotherapy should be studied further to improve survival rates.

Left posterior approach to the superior mesenteric vascular pedicle in pancreaticoduodenectomy for cancer of the pancreatic head.

CONTEXT: Dissection of the superior mesenteric artery is the most important part of a pancreaticoduodenectomy for pancreatic cancer. Since 2005, we have used the left posterior approach for superior mesenteric vascular pedicle dissection, in which the superior mesenteric artery and the superior mesenteric vein are dissected first in a clockwise fashion. OBJECTIVE: This article presents the technique of a left posterior approach and the clinical outcome. PATIENTS: Forty patients underwent a left posterior approach and were compared to 35 patients treated with a conventional dissection. MAIN OUTCOME MEASURES: The differences in surgical technique between the left posterior approach and the conventional method were described, and the short- and long-term surgical results compared patients who underwent the left posterior approach to those who were treated with the conventional method. INTERVENTION: The superior mesenteric vascular pedicle was first dissected from the left lateral border of the superior mesenteric artery. The superior mesenteric vein was also dissected from the left side. Then, the uncinate process and perivascular soft tissue were separated en bloc from the vasculature. RESULTS: No life-threatening complications occurred after the pancreaticoduodenectomies using a left posterior approach. Diarrhea requiring the administration of antidiarrheal agents occurred in 65% of patients; however, planned adjuvant chemotherapy was completed in all patients who did not have an early tumor recurrence. Survival rate was 52.8% at 3 years after surgery. CONCLUSION: After a pancreaticoduodenectomy with a left posterior approach, most patients had various degrees of diarrhea, but the adjuvant chemotherapy was able to be continued with close monitoring. The left posterior approach facilitates understanding of the topographic anatomy in the superior mesenteric vascular pedicle.

Immunohistochemical staining for P1 and P2 promoter-driven hepatocyte nuclear factor-4alpha may complement mucin phenotype of differentiated-type early gastric carcinoma.

Hepatocyte nuclear factor 4alpha (HNF4alpha) isoforms in the human stomach have not been fully investigated. The purpose of the present study was to evaluate the expression of P1 and P2 promoter-driven HNF4alpha (P1 and P2-HNF4alpha) in differentiated-type early gastric carcinomas (DEGC). P1- and P2-HNF4alpha expression was examined immunohistochemically both in non-neoplastic mucosa and carcinoma from surgical specimens. In all samples of non-neoplastic mucosa, foveolar, cardiac, fundic and pyloric gland epithelium was negative for P1-HNF4alpha, but was positive for P2-HNF4alpha. Intestinal metaplasia was positive for P1 and P2-HNF4alpha in all cases. Gastric carcinomas were classified into four mucin phenotypes based on the pattern of mucin expression: gastric, intestinal, mixed and null type. DEGC showed striking differences in the staining pattern for P1-HNF4alpha according to the mucin phenotype. Gastric carcinomas of intestinal, mixed and null type showed high positivity for P1-HNF4alpha, but the gastric type was negative for P1-HNF4alpha in all but one tumor. In contrast, P2-HNF4alpha was expressed in all tumors regardless of the mucin phenotype. Negative expression of P1-HNF4alpha was indicated as one of the useful immunohistochemical markers in the classification of mucin phenotype of both non-neoplastic mucosa and cancers of gastric phenotype.

Intrahepatic cholangiocarcinoma arising 34 years after excision of a type IV-A congenital choledochal cyst: report of a case.

We report a rare case of intrahepatic cholangiocarcinoma (IHCC) arising many years after excision of a type IV-A congenital choledochal cyst. A 44-year-old man was transferred to our hospital with acute cholangitis more than 34 years after several operations for congenital biliary dilatation. Imaging showed a huge tumor in the left medial section of the liver, extending to the porta hepatis. Although he had no jaundice, the intrahepatic bile ducts showed cylinder-like dilatation with narrowing of the hilar bile duct. At surgery, the tumor was found to arise from the dilated intrahepatic bile duct just above the narrow portion. He underwent a left hepatic trisectionectomy with a vascular procedure. Microscopically, the tumor was confirmed to be moderate-to-well-differentiated tubular adenocarcinoma. Thus, when the narrow segment is left untouched, careful long-term follow-up is important to detect new lesions at an early stage.

Portal vein resection in surgery for cancer of biliary tract and pancreas: special reference to the relationship between the surgical outcome and site of primary tumor.

BACKGROUND: Early and late outcomes after superior mesenteric-portal vein resection (VR) combined with pancreaticoduodenectomy, major hepatectomy, or both for pancreaticobiliary carcinoma were retrospectively evaluated. VR is the most frequently used vascular procedure in this field, but an exact role of VR has not been compared according to the primary site of tumor. MATERIALS AND METHODS: Postoperative outcomes were compared between surgery with and without VR in each of the three disease-based groups: hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma with hilar extension (HIC, 56), middle and distal cholangiocarcinoma and gallbladder carcinoma (DGC, 118), and pancreatic head adenocarcinoma (PHC, 77). RESULTS: VR was performed in 19.6% of HIC, 8.5% of DGC, and 45.5% of PHC. In-hospital death was 7.1% (4 of 56) patients with VR (3 of DGC and 1 of PHC). Operations with VR in DGC showed a larger amount of blood loss and more increased ratio of R1operation than those with no VR. In HIC, DGC, and PHC, median survival time of patients with VR was 37, 6.8, and 20 months and that of patients without VR was 42.9, 28.6, and 20.3 months, respectively. VR did not affect survival either in HIC or in PHC; however, in DGC, VR was accompanied with dismal outcome compared with no VR (p=0.001). CONCLUSIONS: Aggressive surgery with VR can be justified both in HIC and in PHC but should not be recommended for DGC. Surgical outcomes of VR differed considerably, depending on the sites of the primary tumor.

[Recurrent gallbladder carcinoma treated with combination chemotherapy with gemcitabine, CPT-11 and S-1--a successful case with metastatic tumors replaced by marked calcification].

We described a case with recurrent gallbladder carcinoma, successfully treated by combination chemotherapy using gemcitabine, CPT-11, and S-1 that was administered as second-line chemotherapy after failure of gemcitabine monotherapy. The level of CA19-9 was normalized three months later, and metastatic tumors of the liver were calcified. She had received the combination chemotherapy for 15 months and is now alive.

Risk factors and prevention of biliary anastomotic complications in adult living donor liver transplantation.

AIM: To evaluate risk factors of biliary anastomotic complications (BACs) and outcomes according to type of biliary reconstruction. METHODS: A total of 33 consecutive adult living donor liver transplantation (LDLT) were reviewed, 17 of which had undergone Duct-to-Duct anastomosis (D-D). The remaining 16 patients received Roux-en-Y anastomosis (R-Y). The perioperative factors, such as the type of graft and the number of graft bile ducts, were analyzed retrospectively. RESULTS: The overall incidence of BACs was 39.4%. The incidence of BACs was significantly higher in the patients with than without neoadjuvant chemotherapy (71.4% vs 10%, P = 0.050). There was no significant difference in the incidence of biliary leakage in patients with D-D vs those with R-Y. The incidence of biliary strictures following the healing of biliary leakage was significantly higher in D-D (60%) than in R-Y (0%) (P = 0.026). However, the incidence of BACs related bacteremia was significantly higher in R-Y than in D-D (71.4% vs 0%, P = 0.008). In D-D, use of T-tube stent remarkably reduced the incidence of BACs, compared with straight tube stent (0% vs 50%, P = 0.049). CONCLUSION: Our experience showed an increase of BACs related bacteremia in the patients with R-Y. Therefore, D-D might be a preferred biliary reconstruction. However, the surgical refinement of D-D should be required because of the high incidence of biliary strictures. Use of the T-tube stent might lead to a significant reduction of BACs in D-D.

Dynamic computed tomography findings of malignant intraductal papillary mucinous tumor compared with invasive ductal adenocarcinoma.

PURPOSE: We evaluated the effectiveness of dynamic computed tomography (CT) imaging in differentiating malignant intraductal papillary mucinous tumor (IPMT) with a large mural nodule from invasive ductal adenocarcinoma (IDAC). MATERIALS AND METHODS: Dynamic CT was done in six IPMT and nine IDAC cases. In the IPMT cases, we made a histological map of the tumor. A region of interest (ROI) was established in the mural nodule of the IPMT, in the IDAC, and in the noncancerous portion of the pancreas. The change of density was analyzed statistically during preenhancement and the early and late phases. These results were compared between the IPMT and IDAC cases. RESULTS: Histologically, most of the mural nodule was papillary adenocarcinoma. In the IPMT cases, the postenhancement density of the mural nodule was significantly higher during the early phase than during the late phase. In IDAC cases, the postenhancement density was significantly higher in the late phase than in the early phase. In the early phase, tumor-pancreas density was significantly higher in the IPMT than in the IDAC. In the late phase, tumor-pancreas density was significantly higher in the IDAC than in the IPMT. CONCLUSION: Dynamic CT is useful for differentiating malignant IPMT with a large mural nodule from IDAC.

[Complete resection of advanced gastric cancer with multiple liver metastases following a bypass operation and one year of chemotherapy].

We report a case of advanced gastric cancer with multiple liver metastases,in which a complete resection was performed following a bypass operation and chemotherapy. A 55-year-old man presented with vomiting and body weight loss. Gastrointestinal endoscopy revealed advanced gastric cancer with pyloric stenosis, and abdominal computed tomography showed multiple liver metastases in segments 2, 3, 5, and 6. A gastrojejunostomy was performed on August 24, 2004. The patient was then treated with 3 cycles of S-1 (120 mg/body, days 1-21) plus cisplatin (80 mg/body,day 8),followed by 8 cycles of weekly paclitaxel (wPTX; 140 mg/body, days 1,8, and 15). The primary tumor and liver tumors remained stable following the 3 cycles of S-1 plus cisplatin, but the liver tumors were considerably smaller after 3 cycles of wPTX. On August 25, 2005, a distal gastrectomy with D2 lymphadenectomy,lateral segmentectomy,and S5 partial hepatectomy was performed. The surgery was completed with no residual macroscopic or microscopic tumors. The patient received 6 cycles of wPTX as adjuvant therapy,and remained well with no evidence of tumor recurrence 28 months after the initial treatment.

Video-assisted living donor hemihepatectomy through a 12-cm incision for adult-to-adult liver transplantation.

OBJECTIVES: There has been remarkable progress in recent technical innovations for laparoscopic hepatectomy. However, a laparoscopic procedure rarely has been indicated for donation of the liver in living-related liver transplantation (LRLT). Here, we described the technique and the outcome of video-assisted donor hepatectomy (VADH) for adult-to-adult LRLT. METHODS: For 13 donors in adult-to-adult LRLT, 3 types of major hepatectomy--right hemihepatectomy (3), and left hemihepatectomy, with or without the caudate lobe (10)--were performed through video-assisted procedures; surgical manipulation via ports or via a 12-cm incision and viewing through a laparoscope or through incision were combined and used. RESULTS: VADH was completed in 13 donors, with a median operation time of 363 +/- 33 minutes and a median blood loss of 302 +/- 191 mL. No complications specific to video-assisted procedures, postoperative bile leak, or bleeding were observed. The restoration of the liver function was smooth, and the use of an analgesic (median: 1.2 times) was reduced, compared with the historical control (median: 3.8 times) that underwent a standard donation of the liver. Currently, all donors are healthy and have returned to their previous activities. The grafts have been functioning well, excluding 3 recipients who succumbed to serious complications unrelated to the video-assisted procedure. CONCLUSION: We have shown a new method of VADH through a 12-cm laparotomy for adult-to-adult LRLT. This technique is as feasible as standard open donor hepatectomy, with less pain and with improved postoperative symptoms.

FK506 may reduce early liver injury following living related liver transplantation.

BACKGROUND/AIMS: We investigated the influence of FK506 which has been used frequently after transplant surgery as an immunosuppressant, on liver injury after partial hepatectomy by comparing laboratory data from donors and recipients after liver transplantation. METHODOLOGY: Seventeen donors and respective recipients who underwent living related donor liver transplantation were included in the present study. Serum levels of transaminases and cytokines were measured and compared preoperatively and in the early period after the operation. RESULTS: Serum level of asparaginic acid aminotransferase in the postoperative day 1 was significantly higher in the donor group. Serum levels of alanine aminotransferase in the early period after the operation were significantly higher in the donor group. Serum levels of interferon y and soluble Fas ligand in the early period after the operation were significantly higher in the donor group. Steroid doses administered were significantly higher in the recipient group. CONCLUSIONS: FK506 administration and steroid administration in larger doses were thought to reduce serum transaminase levels of the recipient group. These findings might suggest that cell-mediated immunity weigh heavier than the operation time of ischemia-reperfusion injury as a cause of liver injury after partial hepatectomy.

Preservation of the left gastric vein in delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy.

The definition of delayed gastric emptying (DGE) after pyloric-preserving pancreaticoduodenectomy (PPPD) varies among surgeons. We compared and evaluated three different definitions reported elsewhere. In addition, we investigated the correlation between multiple surgical factors and recovery of gastric motility. First, 55 consecutive patients were reviewed to assess the three different definitions. Second, surgical factors affecting gastric motility were investigated in 46 patients showing no major complications. All 55 patients underwent PPPD, which was reconstructed with antecolic duodenojejunostomy, with aggressive lymph node dissection and with no mortality. The duration of nasogastric intubation was 2 days, and a solid diet started on the 12th postoperative day (median). Re-nasogastric intubation or emesis was observed in 12.7% of patients. Overall, DGE occurrence rate was 5.5%-29.1%, with striking differences depending on the type of definition. Technically, division of the left gastric vein was accompanied with significantly delayed removal of the nasogastric tube (3 versus 2 days, P = 0.0002) and delayed start on a solid diet (14 versus 9 days, P < 0.0001) compared with its preservation. Antecolic duodenojejunostomy after PPPD improved DGE occurrence despite aggressive surgery, and preservation of LGV accelerated restoration of gastric motility in our experiments. However, an understanding of a common definition of DGE is needed when discussing the outcome of the various interventions.

Repeated hepatectomy for recurrent intrahepatic cholangiocarcinoma: report of two cases.

Repeated hepatectomy for remnant liver recurrence of primary intrahepatic cholangiocarcinoma (ICC) is a seldom-encountered surgical technique because of its poor prognosis. Here, we present two long-term survivors of recurrent ICC by repeated hepatectomy. One patient underwent five hepatectomies in 6 years; first, extended left hepatectomy for a primary mass-forming-type ICC and then four partial hepatectomies for independent recurrent tumors all developing in segment V. The other patient underwent re-hepatectomy for a very large recurrent tumor 7 years after the first left hepatectomy for a primary periductal-infiltrating-type ICC; and has survived for approximately 2 years from the second operation under hepatic arterial infusion chemotherapy. The recurrent tumor in the latter case arose in the segment IV remnant corresponding to the cut margin of the liver after the first inappropriate left hepatectomy. The mode of hepatic recurrence seemed closely related to the portal segmentation: in the first case, intrahepatic metastases via portal tributaries; and in the second, the occult residual cancer spreading widely through bile ductules.

Clinical and surgical factors influencing delayed gastric emptying after pyloric-preserving pancreaticoduodenectomy.

BACKGROUND/AIMS: Delayed gastric emptying (DGE) is the most common and troublesome complication after pylorus-preserving pancreaticoduodenectomy (PPPD), however, definitive treatment has not yet been established. We examined the clinical and surgical factors relevant to DGE using multivariate analyses. METHODOLOGY: Forty-four patients with PPPD were divided into two groups according to reconstructive technique: group A (25), Billroth II type with antecolic duodenojejunostomy and group B (19), Billroth-I type. Multiple clinical and surgical factors influencing DGE were evaluated by univariate and multivariate analyses. RESULTS: The period and output of gastric aspiration were significantly reduced in group A compared with group B (a median of 3 days vs. 14 days and a mean output of 133+26mL vs. 506+80mL, respectively; p<0.0001). Re-insertion of the tube was required in 8% of group A compared with 32% of group B. A liquid or solid diet was started at medians of 8 and 14 days in group A compared with 22 and 28 days in group B (p<0.0001), respectively. Multivariate analyses disclosed that the antecolic duodenojejunostomy and major complication were two exclusive independent predictors of restoration of gastric motility. CONCLUSIONS: Occurrence of DGE was strongly affected by reconstruction technique and major complication. Billroth II reconstruction with antecolic duodenojejunostomy seems to be a useful technique to minimize the occurrence of DGE.

The clinical efficacy of adjuvant systemic chemotherapy with gemcitabine in node-positive pancreatic cancer.

BACKGROUND/AIMS: The effects of gemcitabine in postoperative adjuvant chemotherapy were evaluated in patients suffering from locally advanced pancreatic cancer with lymph node metastases. The results were compared with those of our historical control patients treated by surgery alone. METHODOLOGY: Twenty-one patients with node-positive pancreatic cancer who had undergone a pancreatic resection with curative intent over the five years up to February 2003, were enrolled in this study. Nine cases received postoperative adjuvant chemotherapy with biweekly administration of 1000 mg/m2 gemcitabine, while the remaining 12 cases underwent surgery without any adjuvant chemotherapy. RESULTS: The chemotherapy was well tolerated with only mild symptomatic and hematologic toxicities. The overall cumulative survival rates of the chemotherapy and surgery-alone groups were 86% and 75% at one year, and 50% and 0% at two years, with a median survival of 20.3 months and 15.4 months, respectively (p=0.0084). The disease-free interval was also significantly greater in the chemotherapy group compared with the surgery-alone group (p=0.0244). CONCLUSIONS: Adjuvant systemic chemotherapy utilizing gemcitabine was feasible with acceptable adverse effects and improved the survival rate of patients with node-positive pancreatic cancer. Although further investigation is needed to confirm these results, gemcitabine is a promising agent for the treatment of resectable advanced pancreatic cancer.

Pancreaticogastrostomy: unreliable long-term pancreatic duct patency.

BACKGROUND/AIMS: Long-term patency of pancreaticogastrostomy remains unclear. The purpose of this study is to clarify the long-term patency of pancreaticogastrostomy based on change in the main pancreatic duct diameter. METHODOLOGY: Seventeen of 33 patients who underwent pancreaticogastrostomy in our institution were divided into 2 groups according to the preoperative diameter of main pancreatic duct: the non-dilated group (phi main pancreatic duct < or = 4 mm, 11 patients) and the dilated group (phi main pancreatic duct > or = 5 mm, 6 patients). Clinical and radiological parameters were assessed by a postoperative comparison between the 2 groups. RESULTS: phi main pancreatic duct after operation was dilated in all 11 patients in the non-dilated group, and the difference was significant (p = 0.0003, mean dilatation ratio = 2.6) when compared with phi main pancreatic duct before operation. In contrast, the mean phi main pancreatic duct decreased after operation (mean dilatation ratio = 0.9) in the dilated group. Clinical symptoms (5 patients), impaired endocrine and exocrine pancreatic function (4 and 3 patients, respectively), elevated serum amylase level (6 patients), and pancreatic parenchymal changes on radiological examinations (5 patients) were observed only in the non-dilated group. CONCLUSIONS: Degree of dilatation of main pancreatic duct seems to correspond to likelihood of anastomotic stenosis of pancreaticogastrostomy. Pancreaticogastrostomy has less reliability in terms of the long-term patency in cases having non-dilated main pancreatic duct.

Acute renal failure during the early postoperative period in adult living-related donor liver transplantation.

BACKGROUND/AIMS: Acute renal failure after liver transplantation can occur in some and is an important postoperative complication. Our goal is to clarify the risk factors of acute renal failure after living-related donor liver transplantation (LDLT). METHODOLOGY: From March 1999 to August 2000, ten consecutive patients were investigated the changes of the systemic hemodynamics and the renal function. They were classified into Group A (Creatinine (Cre) was over 2.0 mg/dL) and B (Cre was below 2.0 mg/dL). Retrospective variables were examined with two groups A and B being compared. RESULTS: In both groups, Cardiac Index (CI) was above standard levels. However, the CI levels in Group B were significantly higher than those in Group A (p=0.031). The early postoperative transaminase levels were significantly higher in Group A than in Group B (p=0.049) and graft liver volume/recipient body weight ratio was significantly smaller in Group A than in Group B (p=0.016). CONCLUSIONS: Our study suggests that small-for-size graft or hypovolemia, resulting in the delay of the recovery of graft liver function, may be an important cause of acute renal failure during the early postoperative period in adult LDLT.