Risk factors and prevention strategies for cutaneous squamous cell carcinoma in transplant recipients.

It has been well established that organ transplant recipients (OTRs) are at an increased risk of skin cancer. Studies vary on the exact degree of this risk, but it is likely somewhere between 60 and 100 times more likely that an OTR patient will develop skin cancer. The management of skin cancer burden in OTRs requires a multidisciplinary approach with the transplant team, dermatologists, and oncology. In many major hospital systems, there are dedicated transplant dermatology clinics that allow for specialized and more frequent screenings of this high-risk population. Here we discuss the pathogenesis, presentation, and treatment options used by dermatologists to prevent and treat commonly found skin cancers in this vulnerable population.

Acute Myeloid Leukemia Presenting Less Than 3 Weeks After Living Donor Kidney Transplant: A Case Report.

Acute myeloid leukemia (AML) is a rare malignancy with increased incidence in the kidney transplantation (KT) population for which immunosuppression has been implicated as a putative cause. The average time interval from KT to AML development is 5 years. We present the case of a 61-year-old man who was found to have peripheral blood blasts on a postoperative day 20 routine blood draw after an uneventful unrelated living donor kidney transplant. He subsequently had a bone marrow biopsy and next-generation sequencing (NGS)-based molecular testing, which demonstrated AML characterized by SMC1A and TET2 mutations. He received induction chemotherapy followed by hematopoietic cell transplantation (HCT) from the kidney donor, who happened to be matched at one haplotype. At 12 months after his HCT and 15 months after his KT, his AML remained in remission, normal renal function was preserved, no active graft-versus-host disease was present, and immunosuppression was tapering. With full donor-derived hematopoietic chimerism, we expect to be able to discontinue immunosuppression shortly, thereby achieving tolerance. The short time interval between KT and development of AML suggests the malignancy was likely present before KT. Modern NGS-based analysis offers a promising method of identifying transplant candidates with unexplained hematologic abnormalities on pre-KT testing who may benefit from formal hematologic evaluation.

Deceased donor kidney transplant complicated by spontaneous rupture of native kidney in a HIV patient.

Spontaneous native kidney rupture (SNKR) is a rare occurrence, commonly associated with underlying renal tumors or acquired renal cystic disease in both the kidney transplant (KT) and non-KT populations. Herein, we present a 65-year-old African American man who experienced a non-malignant SNKR 6 days after a deceased donor KT and underwent emergent native nephrectomy. The patient's hospital course was complicated by thrombocytopenia and refractory hypertension. He experienced delayed graft function and was maintained on hemodialysis until post-operative day 30. This case demonstrates an unusual presentation of SNKR in the immediate post-KT setting and illustrates the clinical decision-making algorithm.

Service Requirements of Liver Transplant Anesthesia Teams: Society for the Advancement of Transplant Anesthesia Recommendations.

There are disparities in liver transplant anesthesia team (LTAT) care across the United States. However, no policies address essential resources for liver transplant anesthesia services similar to other specialists. In response, the Society for the Advancement of Transplant Anesthesia appointed a task force to develop national recommendations. The Conditions of Transplant Center Participation were adapted to anesthesia team care and used to develop Delphi statements. A Delphi panel was put together by enlisting 21 experts from the fields of liver transplant anesthesiology and surgery, hepatology, critical care, and transplant nursing. Each panelist rated their agreement with and the importance of 17 statements. Strong support for the necessity and importance of 13 final items were as follows: resources, including preprocedure anesthesia assessment, advanced monitoring, immediate availability of consultants, and the presence of a documented expert in liver transplant anesthesia credentialed at the site of practice; call coverage, including schedules to assure uninterrupted coverage and methods to communicate availability; and characteristics of the team, including membership criteria, credentials at the site of practice, and identification of who supervises patient care. Unstructured comments identified competing time obligations for anesthesia and transplant services as the principle reason that the remaining recommendations to attend integrative patient selection and quality review committees were reduced to a suggestion rather than being a requirement. This has important consequences because deficits in team integration cause higher failure rates in service quality, timeliness, and efficiency. Solutions are needed that remove the time-related financial constraints of competing service requirements for anesthesiologists. In conclusion, using a modified Delphi technique, 13 recommendations for the structure of LTATs were agreed upon by a multidisciplinary group of experts.

Aggressive Epstein-Barr virus-negative B-cell post-transplant lymphoproliferative disorder in a hepatitis C-negative liver transplant recipient who received a hepatitis C-positive graft: Implications for D+/R- hepatitis C virus seroconversion.

Post-transplant lymphoproliferative disorder (PTLD) is an uncommon, but well-described complication after liver transplantation. Most recently, Hepatitis C virus (HCV) has been implicated in the development of PTLD. A HCV-negative 62-year-old man with autoimmune hepatitis received a HCV nucleic acid amplification test-positive liver graft from a 73-year-old brain-dead donor (D+/R-). After his recovery from the operation, the patient was treated for HCV and achieved an undetectable viral load. He was readmitted 6 months after transplant with a spontaneous perisplenic hematoma, weight loss, failure to thrive, low-grade fevers, and abnormal liver function tests. He had a rapid clinical deterioration and expired shortly after admission. His liver biopsy demonstrated EBV-negative monomorphic B-cell PTLD. Our case is the first to report an aggressive early-onset EBV-negative monomorphic B-cell PTLD in a HCV D+/R- liver transplant. This case illustrates the paucity of knowledge on HCV seroconversion and its involvement in EBV-negative monomorphic B-cell PTLD development.

Clostridium paraputrificum septicemia and liver abscess.

We report the first case of a healthy 23-year-old female who underwent an interventional radiology-guided embolization of a hepatic adenoma, which resulted in a gas forming hepatic liver abscess and septicemia by Clostridium paraputrificum. A retrospective review of Clostridial liver abscesses was performed using a PubMed literature search, and we found 57 clostridial hepatic abscess cases. The two most commonly reported clostridial species are C. perfringens and C. septicum (64.9% and 17.5% respectively). C. perfringens cases carried a mortality of 67.6% with median survival of 11 h, and 70.2% of the C. perfringens cases experienced hemolysis. All C. septicum cases were found to have underlying liver malignancy at the time of the presentation with a mortality of only 30%. The remaining cases were caused by various Clostridium species, and this cohort's clinical course was significantly milder when compared to the above C. perfringens and C. septicum cohorts.

Intravenous Acetaminophen for Postoperative Pain Management in Patients Undergoing Living Laparoscopic Living-Donor Nephrectomy.

BACKGROUND: Postoperative pain is a common complication of laparoscopic living-donor nephrectomies (LLDNs). OBJECTIVE: To determine whether intravenous (IV) acetaminophen administration post-LLDN influenced length of stay (LOS) when used for pain management. METHODS: This single-center, retrospective study compared patients undergoing LLDN who had received IV acetaminophen for pain control versus those who did not between June 1, 2011, and November 30, 2015. Patient LOS, 30-day readmissions, frequency of pain assessments, patient-reported pain scores, and opioid administration were assessed. RESULTS: A total of 90 patients were included in the analysis (IV acetaminophen, n = 48; non-IV acetaminophen, n = 42). Patients who did not receive IV acetaminophen were more often older (48.8 ± 12.1 vs 39.3 ± 12.1 years; P = 0.012) and female (71.4% vs 47.9%; P < 0.001). The average LOS was similar between the 2 groups (median = 3.0; interquartile range = [3, 4] vs 3.5 [3, 4]; P = 0.737). The 30-day readmissions were higher in the IV acetaminophen group (16.7%) compared with the group not receiving IV acetaminophen (2.4%; P = 0.033). After the first postoperative day, the frequencies of pain assessments performed were similar among the 2 groups. There was no difference in average pain scores between the groups at any time after LLDN. CONCLUSIONS: Patients receiving IV acetaminophen were found to have no improvements in hospital LOS, average pain score, or opioid requirements compared with patients not receiving IV acetaminophen. Patients who received IV acetaminophen were also found to have a higher 30-day readmission rate.

Current outcomes and indications for cryopreserved vein allografts in hemodialysis access surgery.

INTRODUCTION: Cryopreserved vein allografts (cadaveric vein) have emerged as an option for arteriovenous graft reconstruction; however, indications for their use in hemodialysis access remains to be clearly defined. Observations from our own experience have suggested that cadaveric vein grafts (CVGs) provide good outcomes, particularly in patients with a history of infection, recurrent access failure and advanced age. METHODS: This is a 10-year retrospective study. Primary outcomes were (1) to identify characteristics specific to this patient population and (2) to better define indications for use of cadaveric vein in hemodialysis access creation. RESULTS: Indications for creation of CVGs included patient history of either active or recent infection (41.5%), recurrent access failure (43.4%) or surgeon preference secondary to patients' advanced age (9.4%). Observed primary patency rates were 84.9% (30 days), 22.6% (1 year) and 16.0% (2 years). Secondary patency was 93.4% (30 days), 66.0% (1 year) and 52.8% (2 years). Patient death was the highest cause of graft abandonment (52.9%) followed by thrombosis (19.1%), infection (11.7%) and rupture (11.7%). CVG patency at the time of patient death was 83.7%. CONCLUSIONS: The rates of both primary and secondary patency in CVGs are highly comparable to the reported patency rates of polytetrafluoroethylene (PTFE) grafts and allow for lifelong maintenance of dialysis access. Our observed outcome suggests that CVGs should be considered for patients needing vascular access in the presence of infection. CVGs may likewise be viable alternatives to PTFE grafts in the elderly and patients with limited access options.

The utility of recanalized umbilical vein graft to the hepato-pancreato-biliary surgeon.

BACKGROUND: The authors recently published their experience of recanalizing umbilical veins in deceased liver donors, with recanalized umbilical veins as vascular conduits for meso-Rex bypass procedures. They have since found recanalized umbilical veins to be an excellent, easy to harvest vascular conduit that can be used for multiple vascular procedures and repair. Here, they report their experience using this vessel for bypass and vascular reconstruction. METHODS: They have recanalized umbilical veins and used them in a total of 5 Meso-Rex bypasses; 5 pancreaticoduodenectomies; 1 left hepatic trisegmentectomy with right portal vein (PV) resection and reconstruction; 1 right hepatectomy and 1 adrenalectomy, both with partial inferior vena cava (IVC) resection and reconstruction; 1 coronary-Rex bypass shunt for extrahepatic PV thrombosis; and 1 orthotopic liver transplantation with infrahepatic IVC anastomotic dehiscence patched with umbilical vein graft. Umbilical veins were dilated mechanically and used in situ for the meso-Rex bypass surgery; they were ligated in the space of Rex and then dilated ex vivo otherwise to be used as interposition grafts or a vein patch. RESULTS: A total of 15 hepato-pancreato-biliary procedures were done using the recanalized umbilical vein as graft; 2 patients required thrombectomy postoperatively with reexploration, venotomy, thrombectomy with fogarty catheter, and venotomy closure. CONCLUSION: The umbilical vein graft is a fine vascular conduit and can serve many purposes in hepatobiliary surgery.

Xanthogranulomatous cholecystitis mimicking gallbladder cancer and causing obstructive cholestasis.

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is a destructive inflammatory disease of the gallbladder that can mimic gallbladder carcinoma. METHODS: We present the case of a 35-year-old Hispanic male complaining of right upper quadrant pain and jaundice for 2 months prior to admission. He denied a history of fever, nausea/vomiting, and weight loss. The past medical history was relevant only for diabetes. He had no previous history of jaundice or previous operations. RESULTS: CA19-9 was slightly elevated (52 U/mL). Abdominal ultrasonography showed an irregular thickening of the gallbladder wall and no gallstones were detected. CT scan also revealed an irregular thickening of the wall of the gallbladder body suggestive of malignancy. At laparotomy, the mass was adherent to the duodenum and colon, and although the frozen section biopsy was negative, the intraoperative findings were suggestive of malignancy, and the patient underwent left liver trisegmentectomy, resection of the common bile duct and Roux-en-Y hepaticojejunostomy. Pathological examination unexpectedly revealed XGC without malignancy. CONCLUSIONS: Preoperative and intraoperative differential diagnosis of XGC from gallbladder carcinoma remains a challenge when it is associated with inflammatory involvement of surrounding tissues. Since gallbladder carcinoma and XGC may coexist, radical resection is justified when malignancy cannot be completely ruled out.

Can we direct organ allocation based on predicted outcome? Hepatocellular carcinoma outside of UCSF criteria or retransplant?

BACKGROUND: In this study, we ask between patients with graft failure listed for retransplant and patients with hepatocellular carcinoma (HCC) outside of UCSF criteria, who has the greater survival benefit with transplantation? METHODS: This is a retrospective analysis, of liver transplant (LT) patients, done between February 2002 and December 2009 at our center. Patients were included in the "extended HCC" group if their tumor was pathologically beyond UCSF criteria at LT and in the "redo" group if they underwent LT for graft failure occurring more than 3 months after the initial LT. Extended criteria donors (ECDs) were defined as donors above 70 years old, DCD, serology positive for HCV, and split grafts. RESULTS: There were 25 redos and 37 extended HCC patients. Use of ECDs or high donor risk index organs was associated with poor outcome in both groups (P = 0.005). Overall, the extended HCC population had a much better survival than redos, both at 1 and 3 years. CONCLUSION: These two very different but high risk patient populations have very different survival rates. At a time where regulatory agencies demand more and more with regards to transplant outcomes, we think the transplant community has to reflect on whether allocation justice and fair access to transplant are respected if we start allocating organs based on outcomes.

Liver transplantation for hepatocellular carcinoma: defining the impact of using extended criteria liver allografts.

BACKGROUND: This series compares outcomes of patients with hepatocellular carcinoma (HCC) listed for orthotopic liver transplantation (OLT) within and outside Milan criteria, and determines the impact of extended criteria liver allografts (ECD). METHODS: Records of patients listed for liver transplantation at a single center from 1998 to 2007 were reviewed retrospectively. RESULTS: Ninety-seven HCC patients were listed for OLT, 77 underwent transplantation; 47 received ECDs and 30 standard organs. ECDs were more frequently allocated to outside Milan recipients. Wait time for OLT was shorter for outside Milan patients (4 vs. 7 months P=0.04) but hazard rate of dropout was higher (26%, 46%, and 73% at 6,12, and 24 months compared with 2%, 14%, and 60% P<0.01). Tumor size more than 3 cm (P=0.02) and model for end-stage liver disease score at listing more than 11 (P=0.04) were independent predictors of dropout. Hazard rate of OLT was similar within and outside Milan (61%, 80%, and 90% at 6, 12, and 24 months vs. 60%, 70%, and 86% P=0.38). Post-OLT survival at 1 year and 4 years were 88% and 63% within Milan compared with 79% and 62% among Milan out recipients (P=0.95). No significant post-OLT survival predictor was found. CONCLUSION: The use of ECD organs provided patients with HCCs outside Milan criteria access to liver transplant at a rate comparable to patients within Milan and model for end-stage liver disease HCC priority. Similar patient survival post-OLT can be achieved using standard or ECD organs. The higher risk of drop out in patients outside Milan, and even within Milan, with tumors more than 3 cm justifies the use of ECD organs for timely transplantation.

Liver grafts from selected older donors do not have significantly more ischaemia reperfusion injury.

BACKGROUND: There is a general concern that aged organs are more susceptible to ischaemia. In the light of recent proposals to change the liver allocation system by expanding regional sharing, it is feared that increased cold ischaemia time of grafts from older donors may reduce graft survival. The aim of this study was to correlate donor age and the patterns of ischaemia reperfusion injury and synthetic function early after liver transplantation. METHODS: We performed a retrospective study of first transplants using a single-centre electronic database. Patterns of liver injury (based on transaminases and post-reperfusion biopsy), synthetic function (international normalized ratio [INR]), and graft and patient survival in recipients receiving liver grafts from donors aged ≥ 65 years (group 1, n= 50) were compared with equivalent patterns in a matched cohort of recipients transplanted with grafts from donors aged <65 years (group 2, n= 50). RESULTS: There was no significant difference in transaminase levels from day 0 to day 6 after transplantation. When groups 1 and 2 were subdivided into two subgroups based on the duration of graft cold ischaemia time (<8 h and ≥ 8 h), there was no statistical difference in transaminase levels during the first 7 days. There were two cases (4%) of primary non-function in group 1 and one (2%) in group 2. Initial poor function did not differ significantly between the groups (26% vs. 24%; P= 0.81). In addition, there was no difference in histological changes in post-reperfusion biopsies (21% vs. 34%; P= 0.078) and rate of acute rejection episodes in the first year (30% vs. 32%; P= 0.99). There was no significant difference between groups 1 and 2 in 1-year patient and graft survivals (78% vs. 90% [P= 0.17]; 88% vs. 94% [P= 0.48], respectively). CONCLUSIONS: Judiciously selected livers from aged donors are not associated with major increased susceptibility to ischaemia reperfusion injury.

Massive pulmonary and intracardiac embolism during liver transplantation.

Despite prolonged coagulation times and thrombocytopenia associated with end-stage liver disease, formation of thrombi in the circulation seems to occur more frequently during liver transplant than during any other type of major surgery. Here, we report a case of massive pulmonary and intracardiac embolism that resulted in cardiac arrest and intraoperative death. This was diagnosed by transesophageal echocardiography and occurred shortly after induction of anesthesia and initiation of continuous veno-venous hemofiltration without the concomitant use of antifibrinolytic drugs. We discuss the physiologic changes associated with cirrhosis and liver transplant, and review the literature.

Surgical dilemma: liver resection or liver transplantation for hepatocellular carcinoma and cirrhosis. Intention-to-treat analysis in patients within and outwith Milan criteria.

BACKGROUND: The optimal role of surgery in the management of hepatocellular carcinoma (HCC) is in continuous evolution. OBJECTIVE: The objective of this study was to analyse survival rates after liver resection (LR) and orthotopic liver transplantation (OLT) for HCC within and outwith Milan criteria in an intention-to-treat analysis. METHODS: During 1997-2007, 179 patients with cirrhosis and HCC either underwent LR (n= 60) or were listed for OLT (n= 119). Patients with incidental HCC after OLT, preoperative macrovascular invasion before LR, non-cirrhosis and Child-Pugh class C cirrhosis prior to OLT were eliminated, leaving 51 patients primarily treated with LR and 106 patients listed for primary OLT (84 of whom were transplanted) to be included in this analysis. A total of 66 patients fell outwith Milan criteria (26 LR, 40 OLT) and 91 continued to meet Milan criteria (25 LR, 66 OLT). RESULTS: The median length of follow-up was 26 months. The mean waiting time for OLT was 7 months. During that time, 21 patients were removed from the waiting list as a result of tumour progression. Probabilities of dropout were 2% and 13% at 6 and 12 months, respectively, for patients within Milan criteria, and 34% and 57% at 6 and 12 months, respectively, for patients outwith Milan criteria (P < 0.01). Tumour size >3 cm was found to be the independent factor associated with dropout (hazard ratio [HR] 6.0). Postoperative survival was slightly higher after OLT, but this was not statistically significant (64% for OLT vs. 57% for LR). Overall survival from time of listing for OLT or LR did not differ between the two groups (P= 0.9); for patients within Milan criteria, 1- and 4-year survival rates after LR were 88% and 61%, respectively, compared with 92% and 62%, respectively, after OLT (P= 0.54). For patients outwith Milan criteria, 1- and 4-year survival rates after LR were 69% and 54%, respectively, compared with 65% and 40%, respectively, after OLT (P= 0.42). Tumour size >3 cm was again found to be an independent factor for poor outcome (HR 2.4) in the intention-to-treat analysis. CONCLUSIONS: Survival rates for patients with HCC are similar in LR and OLT. Liver resection can potentially decrease the dropout rate and serve as a bridge for future salvage LT, particularly in patients with tumours >3 cm.

Recanalized umbilical vein conduit for meso-Rex bypass in extrahepatic portal vein obstruction.

BACKGROUND: Meso-Rex bypass is used to treat patients with clinically important extrahepatic portal vein obstruction (EHPVO). Usually, an autologous left internal jugular vein graft is used to bypass the portal blood circulation from the superior mesenteric vein to the left portal vein. Other vascular conduits have included the autogenous saphenous vein, splenic vein, right gastroepiploic vein, and inferior mesenteric vein. METHODS: A total of 20 umbilical veins with attached livers were harvested from 20 deceased liver donors. Umbilical veins were dilated mechanically and checked for patency and communication with the left portal vein. Vein length and diameter after dilatation were recorded. Cross-sections of 15 recanalized umbilical veins were processed by routine histologic examination and stained with hematoxylin and eosin, as well as processed by immunohistochemistry for CD31 and factor VIII antigens. Subsequently, 3 children with EHPVO underwent this modified meso-Rex bypass using the umbilical vein as a vascular conduit. RESULTS: The mean length of harvested umbilical veins was 15 cm (range, 7-21); the mean length of recanalized and usable umbilical veins was 10 cm (range, 5-15). Recanalization was successful in 16 (80%) of the 20 donor umbilical veins. The mean diameter of the umbilical veins after serial dilatation and recanalization was 1.2 cm (range, 1-2). In 11 (73%) of the 15 recanalized vein specimens, the lumen was lined by endothelial cells. In 2 children, the vascular conduit was constructed entirely with native umbilical vein. In the remaining child, 3 cm of umbilical vein was preserved and anastomosed to a mobilized inferior mesenteric vein due to inadequate length. All 3 children had patent bypass and resolution of clinical manifestations of portal hypertension at a mean follow-up of 21 months. CONCLUSION: Meso-Rex bypass may prove to be a definitive treatment for patients with EHPVO. The use of native umbilical vein as a vein conduit achieved decompression of the splanchnic venous system and should be considered a natural alternative to other interposition vein grafts.

Benefits of liver transplantation surgical techniques in the management of extensive retroperitoneal tumors.

BACKGROUND: The potential for massive hemorrhage imposes additional challenge in the management of retroperitoneal tumors. This report details technical considerations for the management of upper retroperitoneal tumors using principles of liver transplantation. METHODS: A retrospective chart review of patients who underwent surgery for extensive retroperitoneal tumors using techniques for liver transplantation from December 2002 to November 2007 was done. RESULTS: Twenty-four patients (14 males and 10 females with a mean age 57 years) underwent major retroperitoneal surgery. Renal cell carcinoma was the most common tumor seen in 17 patients. Mean tumor dimension was 12.4 cm. Abdominal exposure was achieved via bilateral subcostal incision with upper midline extension. Right hepatic lobe mobilization and isolation from the inferior vena cava (IVC) was performed in 23 cases. Fourteen patients had IVC involvement by tumor thrombus, which was infrahepatic in six, retrohepatic in five, and intra-atrial in three patients. Tumor thrombus was removed by cavotomy in seven cases, resection and plasty in four cases, IVC graft reconstruction in two cases, and one patient required IVC and atrial graft reconstruction. Liver resection was needed in seven patients to achieve R0 resection. The Pringle maneuver was used in three patients; total liver vascular isolation with venovenous bypass was required in two cases, transdiaphragmatic intrapericardial IVC control in one case, and cardiopulmonary bypass in one patient. There was no intraoperative or postoperative mortality and mean length of stay was 13 days. CONCLUSION: Liver transplantation surgical principles help achieve exposure and vascular control of major vascular structures that enable safe resection of these extensive retroperitoneal tumors.

Surgical treatment of hepatocellular carcinoma beyond Milan criteria. Results of liver resection, salvage transplantation, and primary liver transplantation.

BACKGROUND: There is no clear consensus regarding the best treatment strategy for patients with advanced hepatocellular carcinoma (HCC). METHODS: Patients with cirrhosis and HCC beyond Milan who had undergone liver resection (LR) or primary orthotopic liver transplantation (OLT) between November 1995 and December 2005 were included in this study. Pathological tumor staging was based on the American Liver Tumor Study Group modified Tumor-Node-Metastasis classification. RESULTS: A total of 23 HCC patients were primarily treated by means of LR, 5 of whom eventually underwent salvage OLT. An additional 32 patients underwent primary OLT. The overall actuarial survival rates at 3 and 5 years were 35% after LR, and 69% and 60%, respectively, after primary OLT. Recurrence-free survival at 5 years was significantly higher after OLT (65%) than after LR (26%). Of the patients who underwent LR, 11 (48%) experienced HCC recurrence only in the liver; 6 of these 11 presented with advanced HCC recurrence, poor medical status, or short disease-free intervals and were not considered for transplantation. Salvage OLT was performed in 5 patients with early stage recurrence (45% of patients with hepatic recurrence after LR and 22% of all patients who underwent LR). At a median of 18 months after salvage OLT, all 5 patients are alive, 4 are free of disease, and 1 developed HCC recurrence 16 months after salvage OLT. CONCLUSION: For patients with HCC beyond Milan criteria, multimodality treatment-including LR, salvage OLT, and primary OLT-results in long-term survival in half of the patients. When indicated, LR can optimize the use of scarce donor organs by leaving OLT as a reserve option for early stage HCC recurrence.

Living-donor hepatectomy in right-sided round-ligament liver: importance of mapping the anatomy to the left medial segment.

Left-sided gallbladder (LSGB) and right-sided round ligament (RSRL) are very infrequent findings, mostly described in Oriental patients, that have associated anatomical variations. An abnormal portal vein branching, mainly to segment IV, is strongly associated with RSRL. Living-donor liver transplantation requires that both the graft and the remnant liver have adequate vascular supply and volumes. Abnormal vascularization of segment IV then threatens this goal. There have been scarce reports of the feasibility of living-donor hepatectomy under these conditions, all in Oriental populations. We present a case of an Occidental living liver donor with RSRL, and discuss the associated anatomical variations of the portal vascular supply of the liver, with its implications in planning a living-donor hepatectomy.