Prospective registry for laparoscopic liver resection.

INTRODUCTION: Laparoscopic liver resection (LLR) has been widely performed throughout the world. Although prospective registry studies to clarify the safety of LLR have been feasible, no prior multicenter prospective study has addressed this issue. We have conducted a multicenter prospective cohort study to reveal the current status of LLR in Japan. METHODS: From April 2015 to March 2016, candidates for LLR were preoperatively enrolled at 12 institutions. The primary end-point was surgical safety, which was evaluated based on surgical factors and on short-term and midterm outcomes. RESULTS: A total of 102 patients were enrolled. Planned laparoscopic procedures included 96 pure laparoscopies, 1 hand-assisted laparoscopy, and 5 hybrid techniques. Non-anatomical partial resection or left lateral sectionectomy were performed in almost all cases. The median duration of surgery was 221 min. The median blood loss was 80.5 mL. Conversion was required for four patients (3.9%). The 90-day postoperative morbidities with grades more severe than II in the Clavien-Dindo classification were observed in six patients (5.9%). The median postoperative hospital stay was 9.5 days. No cases involved reoperation or mortality. CONCLUSION: Minor resection of LLR has been performed safely. To ensure the safe dissemination of LLR, including for major resection, a larger multicenter prospective study is required.

Protocol for laparoscopic cholecystectomy: Is it rocket science?

Laparoscopic cholecystectomy (LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical view of safety (CVS) was first documented two decades ago. Unexpected injuries are principally due to misidentification of human factors. The surgeon's assumption is a major cause of misidentification, and a high level of experience alone is not sufficient for successful LC. We herein describe tips and pitfalls of LC in detail and discuss various technical considerations. Finally, based on a review of important papers and our own experience, we summarize the following mandatory protocol for safe LC: (1) consideration that a high level of experience alone is not enough; (2) recognition of the plateau involving the common hepatic duct and hepatic hilum; (3) blunt dissection until CVS exposure; (4) Calot's triangle clearance in the overhead view; (5) Calot's triangle clearance in the view from underneath; (6) dissection of the posterior right side of Calot's triangle; (7) removal of the gallbladder body; and (8) positive CVS exposure. We believe that adherence to this protocol will ensure successful and beneficial LC worldwide, even in patients with inflammatory changes and rare anatomies.

Graft harvest of right posterior segment for living-donor liver transplantation.

INTRODUCTION: Right posterior segmental graft (RPSG) is an alternative procedure for living-donor liver transplantation (LDLT). Although the first case of RPSG was reported in 2001, it has not been disseminated because of the lack of popularity, technical concerns, and surgical difficulties. PRESENTATION OF CASE: A 37-year-old man with primary sclerosing cholangitis. His spouse was the only transplantation candidate, although she was ABO incompatible. Preoperative investigations revealed that left-lobe graft was insufficient for the recipient and that right-lobe graft was accompanied by donor risk. In RPSG, estimated graft-to-recipient weight ratio (GRWR) and estimated ratio of liver remnant were reasonable. In the donor operation, the right hepatic vein (RHV) and demarcation line were confirmed, and intraoperative cholangiography was performed. The cut line was carefully considered based on the demarcation line and RHV. The RPSG was harvested. Actual GRWR was 0.54. Unfortunately, this recipient showed a poor course and outcome after LDLT. DISCUSSION: Segmental branches of vessels and biliary duct may be not suitable for reconstruction, and surgeons must exercise some ingenuity in the recipient operation. Segmental territory based on inflow and that based on outflow never overlap completely, even in the same segment. The selection of RPSG based only on liver volume may be unfeasible. Liver resection should be carefully considered based on preoperative imaging, and demarcation line and RHV during surgery. CONCLUSION: RPSG is a useful tool for LDLT. However, detailed studies before surgery and careful consideration during surgery are important for RPSG harvest.

Laparoscopic-assisted catheter insertion for continuous ambulatory peritoneal dialysis: A case report of simple technique for optimal placement.

A 40-year-old male underwent tube placement surgery for continuous ambulatory peritoneal dialysis (CAPD). A 2-cm skin incision was made, and the peritoneum was reflected enough to perform secure fixation. A swan-necked, double-felted silicone CAPD catheter was inserted, and the felt cuff was sutured to the peritoneum to avoid postoperative leakage. An adequate gradient for tube fixation to the abdominal wall was confirmed. The CAPD tube was passed through a subcutaneous tunnel. Aeroperitoneum was induced to confirm that there was no air leakage from the sites of CAPD insertion. Two trocars were placed, and we confirmed that the CAPD tube led to the rectovesical pouch. Tip position was reliably observed laparoscopically. Optimal patency of the CAPD tube was confirmed during surgery. Placement of CAPD catheters by laparoscopic-assisted surgery has clear advantages in simplicity, safety, flexibility, and certainty. Laparoscopic technique should be considered the first choice for CAPD tube insertion.

Hematogenous umbilical metastasis from colon cancer treated by palliative single-incision laparoscopic surgery.

Sister Mary Joseph's nodule (SMJN) is a rare umbilical nodule that develops secondary to metastatic cancer. Primary malignancies are located in the abdomen or pelvis. Patients with SMJN have a poor prognosis. An 83-year-old woman presented to our hospital with a 1-month history of a rapidly enlarging umbilical mass. Endoscopic findings revealed advanced transverse colon cancer. computer tomography and fluorodeoxyglucose-positron emission tomography revealed tumors of the transverse colon, umbilicus, right inguinal lymph nodes, and left lung. The feeding arteries and drainage veins for the SMJN were the inferior epigastric vessels. Imaging findings of the left lung tumor allowed for identification of the primary lung cancer, and a diagnosis of advanced transverse colon cancer with SMJN and primary lung cancer was made. The patient underwent local resection of the SMNJ and subsequent single-site laparoscopic surgery involving right hemicolectomy and paracolic lymph node dissection. Intra-abdominal dissemination to the mesocolon was confirmed during surgery. Histopathologically, the transverse colon cancer was confirmed to be moderately differentiated tubular adenocarcinoma. We suspect that SMJN may occur via a hematogenous pathway. Although chemotherapy for colon cancer and thoracoscopic surgery for the primary lung cancer were scheduled, the patient and her family desired home hospice. Seven months after surgery, she died of rapidly growing lung cancer.

Association of transporter associated with antigen processing (TAP) gene polymorphisms in donors with acute cellular rejection in living donor liver transplantation.

BACKGROUND & AIMS: Despite improvements in immunosuppressive therapy, acute cellular rejection (ACR) remains an important cause of mortality and graft loss in patients undergoing liver transplantation. Recently, associations between gene polymorphisms and the incidence of ACR have been reported, though few studies have investigated those polymorphisms in donors. Transporter associated with antigen processing (TAP1 and TAP2) are involved in major histocompatibility complex (MHC) class I antigen-mediated processing and presentation to cytotoxic CD8+ T lymphocytes. The aim of this study was to determine whether TAP1 and TAP2 gene polymorphisms in the donor have affected on ACR incidence in living donor liver transplantation (LDLT). METHODS: We examined 155 LDLTs treated at Nagoya University or Kyoto University from 2004 to 2009 and analyzed the gene polymorphisms of TAP-1 p.Ile333Val, TAP-1 p.Asp697Gly, TAP-2 p.Arg651Cys, and TAP-2 p.Gln687Stop. RESULTS: Thirty-seven recipients developed early ACR. Of the investigated gene polymorphisms, the TAP-1 p.697Gly allele in donors was associated with incidence of early ACR (OR=2.97, 95%CI 1.33-6.63, p=0.008). CONCLUSIONS: The TAP-1 p.697Gly allele in donors was associated with increased incidence of early ACR following LDLT. The TAP-1 697 polymorphism in donors can be genotyped prior to LDLT, which may contribute to individualize immunosuppression strategies for recipients and donor selection.

Impact of glutathione S-transferase T1 gene polymorphisms on acute cellular rejection in living donor liver transplantation.

It has previously been demonstrated that glutathione S-transferase T1 (GSTT1) genetic mismatch between recipient and donor is a risk factor for developing immune-mediated hepatitis following liver transplantation and for antibody-mediated rejection in renal transplantation. Little is known whether the GSTT1 gene polymorphism affects the incidence of acute cellular rejection (ACR) following living donor liver transplantation (LDLT). Patients underwent LDLT at Nagoya University or Kyoto University, Japan, between 2004 and 2009. Genotyping of GSTT1 genes (null or present genotype) was conducted in recipients and donors. A total of 155 LDLT cases were examined. Forty-seven recipients (30.3%) developed early ACR. There was no association of recipient GSTT1 genotype with ACR incidence. However, ACR incidence was significantly higher in recipients transplanted from GSTT1 present genotype donors than in those transplanted from GSTT1 null genotype donors [odds ratio (OR)=2.64, 95% confidence interval (CI)=1.12-5.83, p=0.016]. Moreover, GSTT1 recipient/donor genotype mismatch (present/null or null/present) was significantly associated with ACR development (OR=2.28, 95% CI=1.12-4.61, p=0.022). The genotyping of GSTT1 in recipients and donors might be useful to stratify the liver transplant recipients according to risk of ACR.

Usefulness of endoscope guided transabdominal ultrasonography in T staging of colorectal cancer.

BACKGROUND/AIMS: We investigated the efficacy of endoscope guided transabdominal ultrasonography (EGTUS) for the evaluating the depth of colorectal cancer invasion. METHODOLOGY: The subjects were 52 patients with colon cancer and 30 patients with rectal cancer who underwent transabdominal US and curative surgery. During endoscopy, we applied transabdominal US by filling the area around the tumor with de-gassed water. The accuracy of depth invasion assessment using EGTUS was compared with that using endoscopic, computed tomography (CT), surgical or histological findings. RESULTS: The tumor detection rate was 75.6% (62/82), 88.5% (46/52) for colon cancer and 53.3% (16/30) for rectal cancer. The diagnostic accuracies of EGTUS, endoscopic, CT and surgical findings were 87.1% (54/62), 73.2% (60/82), 66.7% (46/69), 65.9% (54/82), respectively. The diagnostic accuracy of EGTUS was 100% (2/2), 66.7% (4/6), and 90.0% (44/49) for T1, T2 and T3 cancer, respectively. CONCLUSION: The results suggest that EGTUS is useful for evaluating preoperative T staging of colorectal cancer.

Cytokine gene polymorphisms in acute cellular rejection following living donor liver transplantation: analysis of 155 donor-recipient pairs.

PURPOSE: Despite improvements in immunosuppressive therapy, acute cellular rejection (ACR) remains an important cause of graft loss in patients undergoing liver transplantation. Recently, associations between cytokine gene polymorphisms in recipients and the occurrence of ACR have been reported. However, most studies did not investigate gene polymorphisms in donors or were limited by the number of cases investigated. METHODS: We examined 155 living donor liver transplantation (LDLT) patients treated at Nagoya University or Kyoto University from 2004 to 2009. The following gene polymorphisms in recipients and donors were analyzed: tumor necrosis factor A (TNF-A) T-1031C, interleukin 2 (IL-2) T-330G, IL-10C-819T, IL-13C-1111T, and transforming growth factor B (TGF-B) T29C. RESULTS: Forty-seven recipients (30.3 %) developed early ACR. Of the investigated gene polymorphisms, the IL-13 -1111C/C genotype in recipients was significantly associated with a higher incidence of ACR relative to the other two genotypes (OR = 2.64, 95 % CI 1.19-5.86, p = 0.017), while we showed the lack of association between investigated gene polymorphisms in donors and ACR incidence. CONCLUSION: The IL-13 -1111C/C genotype in recipients might be a risk factor for ACR in LDLT, and this might contribute to individualized immunosuppression strategies for recipients. On the other hand, the current study showed no associations of cytokine gene polymorphisms in donors with ACR incidence.

Long-term quality of life of donors after living donor liver transplantation.

The aims of this study were to investigate the long-term effects of living donor liver transplantation (LDLT) on the health-related quality of life (HRQOL) of donors with the Short Form 36 health survey and to determine the risk factors for poor outcomes. Between June 1990 and June 2004, LDLT was performed 1000 times at Kyoto University Hospital. In July 2005, 997 of the 1000 donors were contacted by mail so that data on their HRQOL could be collected. In all, 578 donors responded (ie, there was a 58.0% response rate). The norm-based HRQOL scores for donors were better than the scores for Japanese norms across all time periods. All scores were similar for left lobe donors (n = 367) and right lobe donors (n = 211). For all donors, a multivariate logistic regression analysis revealed that age, the number of months until recovery to the preoperative health status, hospital visits due to donation-related symptoms, rest from work related to donation in the past month, and the existence of 2 or more comorbidities were significantly associated with decreased HRQOL scores. Postoperative complications and recipient mortality were not predictors of poor HRQOL. In conclusion, HRQOL was better for both right lobe donors and left lobe donors versus the Japanese norm population in the long term (mean postdonation period = 6.8 years). However, the prolongation of symptoms or sequelae related to donation lowered mental health or social functioning. The emergence of comorbidities after donation also significantly affected HRQOL in the long term. Careful follow-up and sustained counseling are required for donors with risk factors for lower HRQOL.

Surgical text for orthotopic liver transplantation model with small-for-size graft in the pig: key techniques and pitfalls.

BACKGROUND: Challenges with small-for-size grafts are a critical issue in the liver transplantation field, and a reliable and reproducible animal model is required. METHOD: We performed 50 orthotopic liver transplantations in pigs with a 30% graft, and retrospectively investigated the learning curves. We modified our surgical procedures according to our experience. Here, we describe our current procedures in detail with retrospective evaluation of our experience. The artery to the right lateral lobe crosses the portal vein trunk. A 30% graft is taken using the right lateral lobe attached to a sufficient length of aorta. Hepatic venous plasty is undertaken on the back table to attach a venous patch to the anterior wall of the suprahepatic inferior vena cava, which has no extrahepatic margin. To minimize hypoperfusion to the digestive tract, an aorta-to-aorta anastomosis is performed in a side-to-end fashion in a minimal surgical field before suprahepatic inferior vena cava and portal vein reconstruction. A temporary transjugular portosystemic shunt is also inserted before suprahepatic inferior vena cava reconstruction. The recipient suprahepatic inferior vena cava is clamped at the intramediastinal level, including the margins of the diaphragm in the clamp. RESULTS: Although survival rate during first forty cases were under 0.2, a reasonable survival rate of 0.6 had been achieved after the experiences of forty cases. CONCLUSION: Precedent arterial reconstruction using an aorta-to-aorta anastomosis minimizes congestive damage and shortens operative time. Hepatic venous reconstruction should be completed without any outflow block, by using venous plasty and adequate clamping.

De novo activation of HBV with escape mutations from hepatitis B surface antibody after living donor liver transplantation.

BACKGROUND: De novo activation of HBV occurs after liver transplantation from hepatitis B surface antigen (HBsAg)-negative and hepatitis B core antibody (anti-HBc)-positive donors, even under hepatitis B immunoglobulin (HBIG) prophylaxis. One reason for the activation of HBV is the emergence of HBV with escape mutations from hepatitis B surface antibody (anti-HBs). The aim of this study is to clarify the clinical features for de novo activation of HBV with anti-HBs escape mutations after liver transplantation. METHODS: Clinical features of 75 patients who received HBIG prophylaxis >6 months after liver transplantation with liver grafts from anti-HBc-positive donors were retrospectively analysed. RESULTS: Among the 75 recipients, 19 (25%) developed de novo activation of HBV. Of the 19 recipients, the emergence of HBV with anti-HBs escape mutations was confirmed in 7 patients. The rate of de novo activation of HBV with anti-HBs escape mutations was 12% at 5 years. Sequence analysis revealed mutations in the common 'a' determinant region of the surface gene, including G145R, G145A and Q129P, in HBsAg. Administration of entecavir immediately after the occurrence of de novo HBV activation resolved hepatitis and induced clearance of serum HBsAg and HBV DNA in all four patients receiving entecavir. CONCLUSIONS: Escape mutations from anti-HBs caused de novo activation of HBV under HBIG prophylaxis after liver transplantation. Early administration of entecavir was effective on de novo activation of HBV with anti-HBs escape mutations.

Thrombotic microangiopathy-like disorder after living-donor liver transplantation: a single-center experience in Japan.

AIM: To investigate thrombotic microangiopathy (TMA) in liver transplantion, because TMA is an infrequent but life-threatening complication in the transplantation field. METHODS: A total of 206 patients who underwent living-donor liver transplantation (LDLT) were evaluated, and the TMA-like disorder (TMALD) occurred in seven recipients. RESULTS: These TMALD recipients showed poor outcomes in comparison with other 199 recipients. Although two TMALD recipients successfully recovered, the other five recipients finally died despite intensive treatments including repeated plasma exchange (PE) and re-transplantation. Histopathological analysis of liver biopsies after LDLT revealed obvious differences according to the outcomes. Qualitative analysis of antibodies against a disintegrin-like domain and metalloproteinase with thrombospondin type 1 motifs (ADAMTS-13) were negative in all patients. The fragmentation of red cells, the microhemorrhagic macules and the platelet counts were early markers for the suspicion of TMALD after LDLT. Although the absolute values of von Willebrand factor (vWF) and ADAMTS-13 did not necessarily reflect TMALD, the vWF/ADAMTS-13 ratio had a clear diagnostic value in all cases. The establishment of adequate treatments for TMALD, such as PE for ADAMTS-13 replenishment or treatments against inhibitory antibodies, must be decided according to each case. CONCLUSION: The optimal induction of adequate therapies based on early recognition of TMALD by the reliable markers may confer a large advantage for TMALD after LDLT.

Progressive familial intrahepatic cholestasis: a single-center experience of living-donor liver transplantation during two decades in Japan.

BACKGROUND: Progressive familial intrahepatic cholestasis (PFIC) results in liver cirrhosis. Therefore, some PFIC patients require liver transplantation (LT). Although three types of PFIC have been identified, their etiologies include unknown mechanisms. PATIENTS: A total of 717 recipients who underwent living-donor LT (LDLT) at <20 yr old were enrolled in this study. Among these recipients, 14 PFIC recipients comprising 11 PFIC type 1 (PFIC1) and three PFIC type 2 (PFIC2) were evaluated. RESULTS: Three of 11 PFIC1 recipients died, while all three PFIC2 recipients survived. Eight of 11 PFIC1 recipients showed steatosis after LDLT. Among the eight steatosis-positive PFIC1 recipients, seven showed severe steatosis and seven were complicated with steatohepatitis. Nine of 11 PFIC1 recipients showed fibrosis after LDLT, and eight of the nine fibrosis-positive PFIC1 recipients showed severe fibrosis. In contrast to the PFIC1 recipients, the PFIC2 recipients did not show any steatosis or fibrosis after LDLT. CONCLUSIONS: The clinical courses and outcomes of PFIC1 recipients after LDLT are still not sufficient owing to steatosis/fibrosis, unlike the case for PFIC2 recipients. As PFIC1 patients will require LT during the long-term progression of the disease, further strategy improvements are required for PFIC1 patients.

Pediatric orthotopic living-donor liver transplantation cures pulmonary hypertension caused by Abernethy malformation type Ib.

A 3.3-yr-old boy was diagnosed with PH caused by a PSS of Abernethy malformation type Ib. After control of PH, he underwent OLDLT at 4.9 yr. His PV flowed directly into the confluence of the CCLMHV and the IVC. To shorten the anhepatic phase, hepatic arterial flow was partially maintained. Removal of the native liver began simultaneously with the graft harvest. The proximal PV was cut at the optimal point for reconstruction. The distal PV was cut at the concrescence of the PV and the CCLMHV. After IVC-plasty, the LHV of the graft was attached with an anterior patch by venous grafting and was then anastomosed to the IVC. Although the mPAP temporarily increased above the mean arterial pressure, mPAP was stable during OLDLT. FNH and steatosis were confirmed histopathologically. In summary, pediatric OLDLT was performed successfully in PH caused by PSS.

Posttransplant bacteremia in adult living donor liver transplant recipients.

Infectious complications such as bacteremia after living donor liver transplantation (LDLT) are associated with significant morbidity and mortality. We retrospectively analyzed the frequency and characteristics of posttransplant bacteremia in 181 adult LDLT recipients between April 2006 and November 2009, and we evaluated the risk factors for posttransplant bacteremia. One hundred seventeen episodes of bacteremia occurred in 62 of 181 recipients (34.3%) within 12 days (median) after transplantation (range = 1-71 days). The most frequently isolated pathogens were Pseudomonasaeruginosa (26 episodes), methicillin-resistant coagulase-negative staphylococci (22 episodes), and Enterococcus sp. (11 episodes). The overall survival rate at 1 year for patients with bacteremia (n = 62) was significantly lower than the rate for patients without bacteremia (n = 119; 69.6% versus 92.3%, respectively, P < 0.0001). Multivariate analysis showed that Child-Pugh class C (P = 0.0002), preoperative massive pleural effusion or ascites requiring drainage (P = 0.0384), postoperative cytomegalovirus infection (P = 0.0014), ABO incompatibility (P = 0.0188), and older donor age (P = 0.015) were independent risk factors for postoperative bacteremia. In conclusion, bacteremia occurred at a high rate after adult LDLT and induced a higher mortality rate in those who developed it. Infection control may play a pivotal role in improving early outcomes after LDLT.

Liver transplantation for congenital biliary dilatation: a single-center experience.

BACKGROUND: Congenital biliary dilatation is a rare disease. Although the possibility of refractory cholangitis and/or the frequency of malignant tumors legitimize hepatobiliary surgery, repeated cholangitis and biliary obstruction result in secondary liver cirrhosis even after polysurgery. There are no definitive guidelines on liver transplantation for congenital biliary dilatation. PATIENTS: A total of 1,101 liver transplantation recipients were enrolled in this study. Eleven patients with congenital biliary dilatation including 5 patients with Caroli's disease were retrospectively analyzed in detail. RESULTS: Nine of 11 patients underwent initial operations before liver transplantation while 2 patients with Caroli's disease received liver transplantation as initial surgery, with good outcomes. All patients had intractable symptoms caused by liver cirrhosis, and growth delay was considerable in patients aged <20 years. Histopathological analysis of the native liver revealed hepatic fibrosis (≥F2). One patient with ABO incompatibility died. One patient with Caroli's disease accompanied with intrahepatic carcinoma survives 11.8 years after liver transplantation without any recurrences. CONCLUSIONS: Patients with congenital biliary dilatation with refractory symptoms and complications secondary to liver failure are appropriate candidates for liver transplantation. We suggest that liver transplantation is an effective therapeutic option for patients with congenital biliary dilatation with due consideration to many accompanying factors, such as clinical course, growth delay, image findings and histopathological analysis.

Comprehensive and innovative techniques for liver transplantation in rats: a surgical guide.

AIM: To investigate our learning curves of orthotopic liver transplantation (OLT) in rats and the most important factor for successful surgery. METHODS: We describe the surgical procedures for our rat OLT model, and determined the operator learning curves. The various factors that contributed to successful surgery were determined. The most important surgical factors were evaluated between successful and unsuccessful surgeries. RESULTS: Learning curve data indicated that 50 cases were required for operator training to start a study. Operative time, blood loss, warm ischemic time, anhepatic phase, unstable systemic hemodynamic state, and body temperature after surgery significantly affected surgery success by univariate analysis, while the anhepatic phase was the most critical factor for success by multivariate analysis. CONCLUSION: OLT in rats is the only liver transplantation model that provides clinically relevant and reliable results. Shortened anhepatic phase is key to success in this model.

Portal pressure <15 mm Hg is a key for successful adult living donor liver transplantation utilizing smaller grafts than before.

To prevent small-for-size syndrome in adult-to-adult living donor liver transplantation (A-LDLT), larger grafts (ie, right lobe grafts) have been selected in many transplant centers. However, some centers are investigating the benefits of portal pressure modulation. Five hundred sixty-six A-LDLT procedures using right or left lobe grafts were performed between 1998 and 2008. In 2006, we introduced intentional portal pressure control, and we changed the graft selection criteria to include a graft/recipient weight ratio >0.7% instead of the original value of >0.8%. All recipients were divided into period I (1998-2006, the era of unintentional portal pressure control; n = 432) and period II (2006-2008, the era of intentional portal pressure control; n = 134). The selection of small-for-size grafts increased from 7.8% to 23.9%, and the selection of left lobe grafts increased from 4.9% to 32.1%. Despite the increase in the number of smaller grafts in period II, 1-year patient survival was significantly improved (87.9% versus 76.2%). In 129 recipients in period II, portal pressure was monitored. Patients with a portal pressure <15 mm Hg demonstrated better 2-year survival (n = 86, 93.0%) than patients with a portal pressure >or=15 mm Hg (n = 43, 66.3%). The recovery from hyperbilirubinemia and coagulopathy after transplantation was significantly better in patients with a portal pressure <15 mm Hg. In conclusion, our strategy for A-LDLT has changed from larger graft-based A-LDLT to controlled portal pressure-based A-LDLT with smaller grafts. A portal pressure <15 mm Hg seems to be a key for successful A-LDLT.