A case of coronavirus disease 2019-infected liver transplant donor.

Coronavirus disease 2019 (COVID-19) is a novel infectious disease that continues to spread on a global scale. There has been growing concern about donor-derived transmissions of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Herein, we present the case of a patient who underwent ABO-incompatible living donor liver transplantation without knowing that the liver donor was infected with COVID-19 during the donation procedure. In this case, the donor-derived transmission to the recipient was not identified, and the liver donor was found to be recovering from a COVID-19 infection. The donor-derived transmission was not identified.

Hepatitis B Prophylaxis after Liver Transplantation in Korea: Analysis of the KOTRY Database.

BACKGROUND: Prophylaxis for hepatitis B virus (HBV) recurrence is essential after liver transplantation (LT) in HBV-associated recipients. We conducted real-world analysis of HBV prophylaxis after LT in the Korean population. METHODS: Korean Organ Transplantation Registry (KOTRY) database and additionally collected data (n = 326) were analyzed with special reference to types of HBV prophylaxis. RESULTS: The study cohort comprised 267 cases of living-donor LT and 59 cases of deceased-donor LT. Hepatocellular carcinoma (HCC) was diagnosed in 232 (71.2%) of these subjects. Antiviral agents were used in 255 patients (78.2%) prior to LT. HBV DNA was undetectable in 69 cases (21.2%) and detectable over wide concentrations in the other 257 patients (78.8%) prior to LT. Polymerase chain reaction analysis of the store blood samples detected HBV DNA in all patients, with 159 patients (48.9%) showing concentrations > 100 IU/mL. Post-transplant HBV regimens during the first year included combination therapy in 196 (60.1%), hepatitis B immunoglobulin (HBIG) monotherapy in 121 (37.1%), and antiviral monotherapy in 9 (2.8%). In the second post-transplant year, these regimens had changed to combination therapy in 187 (57.4%), HBIG monotherapy in 112 (34.4%), and antiviral monotherapy in 27 (8.3%). Trough antibody to hepatitis B surface antigen titers > 500 IU/mL and >1,000 IU/mL were observed in 61.7% and 25.2%, respectively. The mean simulative half-life of HBIG was 21.6 ± 4.3 days with a median 17.7 days. Up to 2-year follow-up period, HCC recurrence and HBV recurrence developed in 18 (5.5%) and 6 (1.8%), respectively. HCC recurrence developed in 3 of 6 patients with HBV recurrence. CONCLUSION: Combination therapy is the mainstay of HBV prophylaxis protocols in a majority of Korean LT centers, but HBIG was often administered excessively. Individualized optimization of HBIG treatments using SHL is necessary to adjust the HBIG infusion interval.

Donor safety in living donor liver transplantation: The Korean organ transplantation registry study.

Major concerns about donor safety cause controversy and limit the use of living donor liver transplantation to overcome organ shortages. The Korean Organ Transplantation Registry established a nationwide organ transplantation registration system in 2014. We reviewed the prospectively collected data of all 832 living liver donors who underwent procedures between April 2014 and December 2015. We allocated the donors to a left lobe group (n = 59) and a right lobe group (n = 773) and analyzed the relations between graft types and remaining liver volumes and complications (graded using the Clavien 5-tier grading system). The median follow-up was 19 months (range, 10-31 months). During the study period, 553 men and 279 women donated livers, and there were no deaths after living liver donation. The overall, biliary, and major complication (grade ≥ III) rates were 9.3%, 1.7%, and 1.9%, respectively. The graft types and remaining liver volume were associated with significantly different overall, biliary, and major complication rates. Of the 16 patients with major complications, 9 (56.3%) involved biliary complications (2 biliary strictures [12.5%] and 7 bile leakages [43.8%]). Among the 832 donors, the mean aspartate transaminase, alanine aminotransferase, and total bilirubin levels were 23.9 ± 8.1 IU/L, 20.9 ± 11.3 IU/L, and 0.8 ± 0.4 mg/dL, respectively, 6 months after liver donation. In conclusion, biliary complications were the most common types of major morbidity in living liver donors. Donor hepatectomy can be performed successfully with minimal and easily controlled complications. Our study shows that prospective, nationwide cohort data provide an important means of investigating the safety in living liver donation. Liver Transplantation 23 999-1006 2017 AASLD.

Simplified one-orifice venoplasty for middle hepatic vein reconstruction in adult living donor liver transplantation using right lobe grafts.

Middle hepatic vein (MHV) reconstruction is often essential to avoid hepatic congestion and serious graft dysfunction in living donor liver transplantation (LDLT). The aim of this report was to introduce evolution of our MHV reconstruction technique and excellent outcomes of simplified one-orifice venoplasty. We compared clinical outcomes with two reconstruction techniques through retrospective review of 95 recipients who underwent LDLT using right lobe grafts at our institution from January 2008 to April 2012; group 1 received separate outflow reconstruction and group 2 received new one-orifice technique. The early patency rates of MHV in group 2 were higher than those in group 1; 98.4% vs. 88.2% on postoperative day 7 (p = 0.054) and 96.7% vs. 82.4% on postoperative day 14, respectively (p = 0.023). Right hepatic vein (RHV) stenosis developed in three cases in group 1, but no RHV stenosis developed because we adopted one-orifice technique (p = 0.043). The levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in group 2 were significantly lower than those in group 1 during the early post-transplant period. In conclusion, our simplified one-orifice venoplasty technique could secure venous outflow and improve graft function during right lobe LDLT.

Safety and efficacy of early corticosteroid withdrawal in liver transplant recipients: A randomized controlled trial.

Backgrounds/Aims: Prolonged use of steroids after liver transplantation (LT) significantly increases the risk of diabetes or cardiovascular disease, which can adversely affect patient outcomes. Our study evaluated the effectiveness and safety of early steroid withdrawal within the first year following LT. Methods: This study was conducted as an open-label, multicenter, randomized controlled trial. Liver transplant recipients were randomly assigned to one of the following two groups: Group 1, in which steroids were withdrawn two weeks posttransplantation, and Group 2, in which steroids were withdrawn three months posttransplantation. This study included participants aged 20 to 70 years who were scheduled to undergo a single-organ liver transplant from a living or deceased donor at one of the four participating centers. Results: Between November 2012 and August 2020, 115 patients were selected and randomized into two groups, with 60 in Group 1 and 55 in Group 2. The incidence of new-onset diabetes after transplantation (NODAT) was notably higher in Group 1 (32.4%) than in Group 2 (10.0%) in the per-protocol set. Although biopsy-proven acute rejection, graft failure, and mortality did not occur, the median tacrolimus trough level/dose/weight in Group 1 exceeded that in Group 2. No significant differences in safety parameters, such as infection and recurrence of hepatocellular carcinoma, were observed between the two groups. Conclusions: The present study did not find a significant reduction in the incidence of NODAT in the early steroid withdrawal group. Our study suggests that steroid withdrawal three months posttransplantation is a standard and safe immunosuppressive strategy for LT patients.

Multiple Graft Bile Ducts Do Not Affect the Postoperative Outcomes of Right Lobe Living Donor Liver Transplantation.

Multiple graft duct openings are associated with a high incidence of biliary complications (BCs), and biliary reconstruction for multiple graft bile ducts (BDs) remains a surgical challenge during living donor liver transplantation (LDLT). In particular, biliary reconstruction using "high biliary radicals (HBR)" of recipients for multiple graft BDs has a high probability of BCs. Herein, we analyzed outcomes by retrospectively reviewing 283 patients who underwent right lobe LDLT from January 2013 to September 2019. In total, 112 LDLT procedures using grafts with multiple BDs have been performed under our policies. In recent cases with 2 orifices located on the same hilar plate, we did dunking with a mucosal eversion technique instead of ductoplasty. When 2 orifices are located far apart on different hilar plates, we attempted to perform separate duct-to-duct anastomosis (DDA) using HBR of the recipient instead of hepaticojejunostomy. Among patients with multiple graft BDs, 20 underwent ductoplasty, 50 were treated using dunking with mucosal eversion technique, and 40 underwent separate DDA using HBR (HBR group). The incidence rates of biliary leakage and stricture were 8.9% and 10.7% in the multiple BD group, respectively, congruent with the outcomes of the single BD group. In subgroup analysis, we compared clinical outcomes between the HBR and single BD groups; the incidence of BCs in the HBR group was 15.0%, comparable to that of the single BD group. In conclusion, multiple graft BDs do not negatively impact the BC rate compared with single-graft BD when applying our technique to prevent BCs.

Technical Refinement to Prevent Hepatic Outflow Disturbance in Right Lobe Living Donor Liver Transplantation: The New Simplified One-Orifice Venoplasty Technique.

Middle hepatic vein (MHV) reconstruction is often essential to avoid hepatic congestion and serious graft dysfunction in living donor liver transplantation (LDLT). This article introduces the evolution of our MHV reconstruction technique and the excellent outcomes of a new simplified one-orifice venoplasty. We compared clinical outcomes among 3 types of one-orifice techniques through a retrospective review of 378 recipients who underwent LDLT using a modified right lobe graft at our institution from January 2008 to December 2018; group I (n = 34) received separate outflow reconstruction, group II (n = 166) received the one-orifice technique to create a wider single outflow with patchwork, and group III (n = 178) received the more simplified one-orifice technique in which neo-MHV was reconstructed into the right hepatic vein without patch venoplasty. Patient demographic characteristics did not differ significantly among the 3 groups, but cold ischemic time and operative time in groups II and III were significantly shorter than those in group I. Moreover, the early patency rates of MHV in groups II and III were higher than those in group I. In particular, group I received an MHV or right hepatic vein stenting more frequently than group II or III during the early posttransplant period. In conclusion, this new simplified one-orifice technique could be an effective method to overcome technical difficulties and the outflow disturbance during right lobe LDLT without complex benchwork to create a large outflow.

Upper Midline Incision Could Become Standard Practice for Living Donor Right Hepatectomy.

BACKGROUND: Laparoscopic approaches have not been performed in living right donor hepatectomy (LDRH) because these are more technically demanding and are associated with increased donor morbidity. Instead, several studies have described LDRH using an upper midline incision (UMI) to reduce donor morbidity. Herein, we describe our experience with small UMI as a standard procedure for LDRH. METHODS: We retrospectively reviewed the outcomes of 444 LDRH at our institution from January 2010 to June 2019; 124 donors received LDRH using UMI (UMI group) and 320 donors underwent LDRH using a J-shaped incision (J-shaped group). This incision has been performed regardless of graft type, body mass index, graft weight, or vascular variations. Patient demographic characteristics, intraoperative parameters, laboratory data, and postoperative complications were compared between the 2 groups. RESULTS: The mean size of the UMIs was 12.4 cm (range, 11-16 cm) and the overall complication rates did not differ significantly between the 2 groups. Most postoperative outcomes were not different between the 2 groups, but the length of hospital stay and operation time in the UMI group were significantly lower than those in the J-shaped group. In multivariate logistic regression analyses, only large grafts (>900 g) and significant hepatic steatosis (≥15%) were significant risk factors for difficult operation but not related to type of incision. CONCLUSION: LDRH could be safely performed with a small UMI and could be considered as standard practice during LDRH.

Predicting the Recurrence of Hepatocellular Carcinoma after Primary Living Donor Liver Transplantation Using Metabolic Parameters Obtained from 18F-FDG PET/CT.

This study evaluated the prognostic value of metabolic parameters based on the standardized uptake value (SUV) normalized by total body weight (bwSUV) and by lean body mass (SUL) measured on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) for predicting tumor recurrence after primary living donor liver transplantation (LDLT) in patients with hepatocellular carcinoma (HCC) without transplantation locoregional therapy. This retrospective study enrolled 49 patients with HCC. The maximum tumor bwSUV (T-bwSUVmax) and SUL (T-SULmax) were measured on PET. The maximum bwSUV (L-bwSUVmax), mean bwSUV (L-bwSUVmean), maximum SUL (L-SULmax), and mean SUL (L-SULmean) were measured in the liver. All metabolic parameters were evaluated using survival analyses and compared to clinicopathological factors. Tumor recurrence occurred in 16/49 patients. Kaplan-Meier analysis revealed that all metabolic parameters were significant (p < 0.05). Univariate analysis revealed that prothrombin-induced by vitamin K absence or antagonist-II; T-stage; tumor number; tumor size; microvascular invasion; the Milan criteria, University of California, San Francisco (UCSF), and up-to-seven criteria; T-bwSUVmax/L-bwSUVmean; T-SULmax; T-SULmax/L-SULmax; and T-SULmax/L-SULmean were significant predictors. Multivariate analysis revealed that the T-SULmax/L-SULmean (hazard ratio = 115.6; p = 0.001; cut-off, 1.81) and UCSF criteria (hazard ratio = 172.1; p = 0.010) were independent predictors of tumor recurrence. SUL-based metabolic parameters, especially T-SULmax/L-SULmean, were significant, independent predictors of HCC recurrence post-LDLT.

Renal safety of tenofovir disoproxil fumarate and entecavir in liver transplant patients: a nationwide Korean registry study.

BACKGROUND AND AIMS: Tenofovir disoproxil fumarate (TDF) and entecavir (ETV) have been recommended after liver transplantation to prevent recurrence of hepatitis B virus infection. Despite its proven efficacy, the renal safety of TDF has not been established in liver transplant recipients. We aimed to compare the effects of TDF and ETV on renal function in liver transplant recipients and to evaluate risk factors for renal dysfunction after liver transplantation. METHODS: This is a retrospective, observational multicenter study of data from the Korean Organ Transplantation Registry. We included adults who underwent liver transplantation for hepatitis B virus-related complications from April 2014 to December 2017 and received TDF or ETV post-transplantation. Renal dysfunction was defined as an estimated glomerular filtration rate decline by at least 20% from baseline (1 month post-transplantation). Median duration of follow-up was 29 months (interquartile range 19-42). RESULTS: A total of 804 liver transplant patients were included. The cumulative probability of renal dysfunction was significantly higher in the TDF group than in the ETV group. Multivariable analysis confirmed that TDF was independently associated with an increased risk of renal dysfunction (hazard ratio = 1.47, 95% confidence interval 1.12-1.92; p = 0.005). Independent risk factors for renal dysfunction included older age, worse baseline renal function, and low body mass index. Overall survival rate was significantly lower in patients with renal dysfunction than in those without. CONCLUSIONS: In this nationwide study, the use of TDF was associated with an increased risk of renal dysfunction, when compared with ETV.

Outcomes after liver transplantation in Korea: Incidence and risk factors from Korean transplantation registry.

BACKGROUND/AIMS: To analyze the incidence and risk factors of outcomes after liver transplantation (LT) in the Korean population. METHODS: This study analyzed data from the liver cohort of Korean Organ Transplantation Registry (KOTRY) who had LT between May 2014 and December 2017. Study measures included the incidence of post-LT outcomes in recipients of living donor LT (LDLT) and deceased donor LT (DDLT). Cox multivariate proportional hazards model was used to determine the potential risk factors predicting the outcomes. RESULTS: A total of 2,563 adult recipients with LT (LDLT, n=1,956; DDLT, n=607) were included, with mean±standard deviation age of 53.9±8.9 years, and 72.2% were male. The post-LT outcomes observed in each LDLT and DDLT recipients were death (4.0% and 14.7%), graft loss (5.0% and 16.1%), rejection (7.0% and 12.0%), renal failure (2.7% and 13.8%), new onset of diabetes (12.5% and 15.4%), and hepatocellular carcinoma (HCC) recurrence (both 6.7%). In both LDLT and DDLT recipients, the most common post-LT complications were renal dysfunction (33.6% and 51.4%), infection (26.7% and 48.4%), and surgical complication (22.5% and 23.9%). Incidence of these outcomes were generally higher among recipients of DDLT than LDLT. Multivariate analysis indicated recipient age and DDLT as significant risk factors associated with death and graft loss. DDLT and ABO incompatible transplant were prognostic factors for rejection, and HCC beyond Milan criteria at pre-transplant was a strong predictor of HCC recurrence. CONCLUSION: This study is a good indicator of the post-LT prognosis in the Korean population and suggests a significant burden of post-LT complications.

A comparative study of postoperative outcomes between minimally invasive living donor hepatectomy and open living donor hepatectomy: The Korean organ transplantation registry.

BACKGROUND: This study evaluated the safety and effectiveness of minimally invasive living donor hepatectomy in comparison with the open procedure, using Korean Organ Transplantation Registry data. METHODS: We reviewed the prospectively collected data of all 1,694 living liver donors (1,071 men, 623 women) who underwent donor hepatectomy between April 2014 and December 2017. The donors were grouped on the basis of procedure type to the minimally invasive procedure group (n = 304) or to the open procedure group (n = 1,390) and analyzed the relationships between clinical data and complications. RESULTS: No donors died after the procedure. The overall complication rates after operation in the minimally invasive procedure group and the open procedure group were 6.2% and 3.5%, respectively. Biliary complications were the most frequent events in both groups (minimally invasive procedure group, 2.4%; open procedure group, 1.6%). The majority of complications occurred within 7 days after surgery in both groups. The duration of hospitalization was shorter in the minimally invasive procedure group than in the open procedure group (9.04 ± 3.78 days versus 10.29 ± 4.01 days; P < .05). CONCLUSION: Based on its similar outcomes in our study, minimally invasive donor hepatectomy cannot be an alternative option compared with the open procedure method. To overcome this, we need to ensure better surgical safety, such as lower complication rate and shorter duration of hospitalization.

Safety and Efficacy of Living Donor Hepatectomy Without Systemic Heparinization: Short- and Long-Term Outcomes.

There is no consensus regarding the use of systemic heparin, and long-term outcomes of living donor hepatectomy (LDH) without systemic heparinization have not yet been determined. This study was performed to determine whether systemic heparinization can be omitted during LDH, with a focus on donor safety and long-term outcomes. We retrospectively analyzed the outcomes of 175 cases of LDH performed in our institution between January 2011 and December 2014: group I (n = 79) received systemic heparinization, whereas group II (n = 96) did not, but liver graft was flushed with a heparinized perfusate. Postoperative bleeding requiring blood transfusion or intervention was more frequent in group I than in group II (P = .028). The decreases in donor hemoglobin and hematocrit levels, and platelet count during the early postoperative period, were greater in group I than in group II. In multivariate analysis, systemic heparin was the only independent risk factor for blood transfusion (odds ratio [OR] = 5.114; 95% confidence interval [CI]: 1.201-21.775; P = .027) and significant postoperative bleeding (OR = 7.731; 95% CI: 1.345-44.429; P = .022) after LDH. Most postoperative complications including graft vascular thrombosis were similar between the 2 groups, as was the survival rate, and neither graft loss due to vascular thrombosis nor non-anastomotic biliary stricture was evident. In conclusion, omission of systemic heparinization during LDH is a feasible and safe option without adverse effects.

Feasibility of Dual Living Donor Liver Transplantation From Donors With Complex Portal Vein Variations.

Living donor liver transplantation (LDLT) from donors with complex portal vein anomalies has been considered a challenging procedure because vasculobiliary variations of the donor's liver may lead to significant increases in donor and recipient complications. The use of donors with anatomic variations may be considered under the accurate preoperative planning if a more suitable donor is not available. We report a successful dual LDLT for 2 donors with portal vein anomaly to overcome the small-for-size graft syndrome and secure donor safety. A 62-year-old man was referred to our institution for liver transplant because of hepatitis B-related liver cirrhosis with hepatocellular carcinoma. The only available donors were his son and his daughter-in-law, one with type IV portal venous anatomic variation and the other with type III variation. Neither of the 2 available donors were suitable as a single donor because of the complexity of the portal vein reconstruction and the donor's safety. Therefore, the decision was made to perform LDLT using dual graft, and we planned to harvest the right posterior sector graph from the first donor together with the left lobe graft of the second donor. Donor hepatectomy and recipient total hepatectomy were performed in the usual manner. He has recovered well with normal graft function, and there has been no tumor recurrence after dual LDLT. Dual graft LDLT using right posterior sector and left lobe graft could be undertaken successfully to overcome the small-for-size graft syndrome and secure the safety of donors in cases with the complex portal vein anomalies.

Novel Method for Reconstructing Multiple Graft Bile Ducts During Right Lobe Living Donor Liver Transplant: Dunking With Mucosal Eversion Technique.

BACKGROUND: Multiple graft bile ducts (BDs) and anastomoses have been considered as risk factors for biliary complications after living donor liver transplant (LDLT). Various surgical techniques have been introduced, and most surgeons perform unification ductoplasty for multiple adjacent BDs during LDLT. However, this could cause hemobilia and is difficult to perform when 2 ductal orifices are far apart or show a size discrepancy. METHODS: Here, we introduce our novel reconstruction technique for multiple adjacent graft BDs and discuss its effects on postoperative outcomes compared with ductoplasty. We compared the clinical outcomes of 2 biliary reconstruction techniques by retrospectively reviewing 58 recipients who underwent LDLT with right lobe grafts using these 2 techniques at our institution between January 2013 and September 2018: group 1 (n = 20) received ductoplasty, and group 2 (n = 38) was treated with dunking with mucosal eversion technique. RESULTS: Overall biliary complication rates were 20.0% in group 1 and 10.5% in group 2 (P = .32). Biliary stricture in group 2 was not frequent compared with that in group 1 (7.9% vs 15.0%, P = .398). Moreover, incidence of biliary stricture in group 2 was not different than that in the group using graft with single BD during the same period (P > .624). CONCLUSIONS: Our novel technique could be a useful method for reconstructing adjacent BDs in LDLT and the best alternative to ductoplasty. Moreover, it seems to be a reasonable option when 2 orifices are far apart or show a size discrepancy.

A Multicenter, Randomized, Open-Label Study to Compare Micafungin with Fluconazole in the Prophylaxis of Invasive Fungal Infections in Living-Donor Liver Transplant Recipients.

BACKGROUND: Although invasive fungal infections (IFIs) contribute to substantial morbidity and mortality in liver transplant recipients, only a few randomized studies analyzed the results of antifungal prophylaxis with echinocandins. The aim of this open-label, non-inferiority study was to evaluate the efficacy and safety of micafungin in the prophylaxis of IFIs in living-donor liver transplantation recipients (LDLTRs), with fluconazole as the comparator. METHODS: LDLTRs (N = 172) from five centers were randomized 1:1 to receive intravenous micafungin 100 mg/day or fluconazole 100~200 mg/day (intravenous or oral). A non-inferiority of micafungin was tested against fluconazole. RESULTS: The per-protocol set included 144 patients without major clinical trial protocol violations: 69 from the micafungin group and 75 from the fluconazole group. Mean age of the study patients was 54.2 years and mean model for end-stage liver disease (MELD) score amounted to 16.5. Clinical success rates in the micafungin and fluconazole groups were 95.65% and 96.10%, respectively (difference: - 0.45%; 90% confidence interval [CI]: - 6.93%, 5.59%), which demonstrated micafungin's non-inferiority (the lower bound for the 90% CI exceeded - 10%). The study groups did not differ significantly in terms of the secondary efficacy endpoints: absence of IFIs at the end of the prophylaxis and the end of the study, time to proven IFI, fungal-free survival, and adverse reactions. A total of 17 drug-related adverse events were observed in both groups; none of them was serious and all resolved. CONCLUSION: Micafungin can be used as an alternative to fluconazole in the prevention of IFIs in LDLTRs. CLINICAL TRIALS REGISTRATION: NCT01974375.

New-onset diabetes after adult liver transplantation in the Korean Organ Transplantation Registry (KOTRY) study.

BACKGROUND: New-onset diabetes after transplantation (NODAT) is a serious complication following liver transplantation (LT). The present study aimed to investigate the incidence of and risk factors for NODAT using the Korean Organ Transplantation Registry (KOTRY) database. METHODS: Patients with history of pediatric transplantation (age ≤18 years), re-transplantation, multi-organ transplantation, or pre-existing diabetes mellitus were excluded. A total of 1,919 non-diabetic adult patients who underwent a primary LT between May 2014 and December 2017 were included. Risk factors were identified using Cox regression analysis. RESULTS: NODAT occurred in 19.7% (n=377) of adult liver transplant recipients. Multivariate analysis showed steroid use, increased age, and high body mass index (BMI) in recipients, and implantation of a left-side liver graft was closely associated with NODAT in adult LT. In living donor liver transplant (LDLT) patients (n=1,473), open donor hepatectomy in the living donors, steroid use, small for size liver graft (graft to recipient weight ratio ≤0.8), increased age, and high BMI in the recipient were predictive factors for NODAT. The use of antimetabolite and basiliximab induction reduced the incidence of NODAT in adult LT and in adult LDLT. CONCLUSIONS: Basiliximab induction, early steroid withdrawal, and antimetabolite therapy may prevent NODAT after adult LT. High BMI or advanced age in liver recipients, open donor hepatectomy in living donors, and small size liver graft can predict the occurrence of NODAT after adult LT or LDLT.

Comparison of hepatic artery reconstruction using surgical loupe and operating microscope during living donor liver transplantation focusing on the beginner's point.

BACKGROUNDS/AIMS: Hepatic artery (HA) reconstruction during living donor liver transplantation (LDLT) has been performed by experienced microsurgeons with operative microscope in most centers. However, it takes long time to learn the skills and so, to simplify this procedure, transplant surgeons recently performed this procedure using surgical loupe. METHODS: This study retrospectively reviewed outcomes of 237 LDLTs at our institution from January 2012 to October 2016. In group I, HA reconstruction was performed under operative microscope by an experienced microsurgeon and in group II, it was performed using surgical loupe by a transplant surgeon with little experience for arterial anastomosis. RESULTS: There was no difference in most perioperative outcomes between two groups except mean time required for HA reconstruction (24.2±4.3 vs. 20.9±6.9 minutes, p=0.001). Multivariable regression modeling to adjust for baseline differences showed that the use of surgical loupe was not associated with either HA thrombosis or intraoperative HA revision rate. CONCLUSIONS: HA reconstruction under surgical loupe can be performed simply and yields results as good as with operative microscopy, even when the transplant surgeon has less experience with HA anastomosis.

Sarcomatoid carcinoma of common bile duct: a case report.

Sarcomatoid carcinomas (carcinosarcomas) are rare lesions in the hepatobiliary pancreatic system. We present an extremely rare case of sarcomatoid carcinoma of the common bile duct. The tumor showed a biphasic pattern of intermixed carcinomatous (adenocarcinoma) and sarcomatoid elements (spindle and giant cells). By immunohistochemical staining, cytokeratin and vimentin were demonstrated in the sarcomatoid component. The proliferative activity and the oncoproteins expressed by the tumor were investigated by the PCNA, Ki-67, p53 and Bcl-2 in different tumor fields. Overall, the intensities of PCNA and p53 were moderate in the sarcomatoid component, but mild in the carcinomatous component. However, Ki-67 and Bcl-2 were both negative in the carcinomatous and sarcomatoid components. The possible histogenensis of sarcomatoid carcinoma of the common bile duct is discussed. We report upon an additional extremely rare case of sarcomatoid carcinoma arising in the common bile duct together with its immunohistochemical characteristics, and give details of its proliferative activity and oncoprotein expression.

Salvage dual graft living donor liver transplantation after major hepatectomy.

Salvage living donor liver transplantation (LDLT) after major hepatectomy has been considered a challenging procedure due to operative complexity. We report a successful case of salvage dual graft LDLT after right hepatectomy. A 48-year-old male was transferred to Daegu Catholic University Medical Center because of duodenal variceal bleeding. He underwent right hepatectomy due to hepatocellular carcinoma four years prior. We performed LDLT with dual graft from his wife and sister. During operation, portal vein anastomosis of the right lobe graft was performed using an interposing cadaveric iliac vein graft and the right gastroepiploic artery was anastomosed to the hepatic artery of the left lobe graft. Adequate graft inflow was demonstrated by postoperative imaging studies. He has been doing well with normal graft function for 31 months. Salvage dual graft LDLT could be undertaken successfully in patients with prior major hepatectomy under accurate preoperative planning and proper surgical techniques.