Role of hand-assisted laparoscopic surgery in living-donor right liver harvest.

OBJECTIVE: The cosmetic aspects of abdominal skin incisions are a matter of concern for both live liver donors and surgeons. We performed a prospective comparative study on the use of minilaparotomy to perform right liver graft harvests with and without hand-assisted laparoscopic surgery (HALS). METHODS: Young donors were indicated for surgery using minilaparotomy with or without HALS. In the non-HALS group (n = 20), a 10-12-cm-long right subcostal incision was used for right liver graft harvest. In the HALS group (n = 20), an 8-cm-sized right subcostal incision was used for hand assistance and 3 laparoscopic holes made for manipulation. The retrohepatic inferior vena cava (IVC) was initially laparoscopically dissected while using air inflation. The skin incision was extended to 10-12 cm, and then hilar dissection and hepatic transection were performed through the skin incision. RESULTS: In all 40 donors in the study cohort, safe uneventful harvesting of the right liver grafts was successfully achieved through the minilaparotomy incisions. The HALS group required an additional 30 minutes for laparoscopic preparation and dissection compared with the non-HALS group. HALS facilitated retrohepatic IVC dissection, and the remaining part of the surgery was the same as that for minimal-incision surgery. The minimal skin incision for the delivery of the liver from the abdomen was an average 10 cm for grafts <500 g and 12 cm for grafts ≥700 g. Compared with the patient profiles, there were no differences regarding donor age, body mass index, graft weight, intraoperative blood loss, postoperative increase in peak liver enzymes, total hospital stay, and incidence of postoperative complications. CONCLUSIONS: HALS facilitates the performance of donor hepatectomy with the use of a minimal incision, which probably allows for a wider selection of living donors.

Survival rates among patients awaiting deceased donor liver transplants at a single high-volume Korean center.

BACKGROUND: Since the establishment of the Korean Network for Organ Sharing (KONOS) in 2000, thousands of patients have been enrolled on the waiting list, but only a small proportion have received a deceased donor liver transplantation. This report on waiting list mortality in Korea based on data from a single institution. METHODS: The 1772 patients enrolled on the waiting list between February 2000 and December 2011 either have not yet received at the time of analysis or have died before receiving an organ. Survival information was obtained in February 2012 by reviewing medical records or by telephone. We excluded patients who died immediately after enrollment or after retransplantation. RESULTS: Primary diagnoses of those awaiting transplantation were hepatitis B virus-associated cirrhosis (63.7%), alcoholic liver disease (14.3%), hepatitis C virus-associated cirrhosis (13.8%), and acute liver failure due to other causes (8.1%). The priority status of patients on the waiting list was KONOS status 1 (highest priority) in 3.8%, status 2A in 3.9%, status 2B in 41.9%, status 3 to 7 (lowest priority) in 50.5%. Their median survival periods were 1, 1, 18, and 59 months, respectively. The mean Child-Pugh score was 8.5 ± 2.5 and Model for End-stage Liver Disease (MELD) score 18.1 ± 9.8. CONCLUSIONS: Patients with high MELD scores or hepatocellular carcinoma succumbed soon after being entered on to the waiting list. By increasing organ donation rates and developing a risk-based allocation system, it should be possible to reduce mortality among patients on organ waiting lists.

Unification venoplasty to cope with recipient portal vein anomaly during living donor liver transplantation.

PURPOSE: To cope with recipient portal vein (PV) anomalies, such as early branching of the right posterior section (RPS), during living donor liver transplantation (LDLT) surgery, we performed a simulation study to standardize the surgical technique for unification portal venoplasty. METHODS: This study included an observational analysis of conventional methods utilizing RPS PV, simulation-based design of a new surgical technique, and clinical application of this new technique. RESULTS: In a case encountering RPS PV, a mild anastomotic PV stenosis was persistent over 6 months postsurgery, indicating the need for technical refinement. After computational simulation analysis, we found that simple suturing of the PV branch patch automatically resulted in a funnel-shaped elongation. A prospective recipient study (n = 30) indicated that usual PV reconstruction via the PV bifurcation method is feasible in the absence of unusual donor or recipient PV anomaly. Retrospective living donor PV anatomy analysis (n = 20) revealed that 20-mm-long limbs of the first-order PV branches are necessary to make a 10- to l5-mm-long funneled PV stump. This technique of unification venoplasty for an anomalous recipient PV was applied to an adult patient undergoing LDLT with a right liver graft, for which it was shown to be technically feasible and effective. CONCLUSIONS: A simplified unification venoplasty technique was developed to cope with a recipient PV anomaly in adult LDLT.

Long-term survival outcomes for living donor liver transplant recipients with pathologically nonviable hepatocellular carcinoma.

PURPOSE: Complete necrosis of hepatocellular carcinoma (HCC) lesions has occasionally been found by explant pathology after pretransplant neoadjuvant treatment. This study sought to investigate the long-term prognostic effect of loss of tumor viability after HCC treatment in living donor liver transplant (LDLT) recipients. METHODS: We reviewed retrospectively the 5-year records of 37 patients who demonstrated nonviable HCC on explant pathology. RESULTS: The most common primary disease was hepatitis-B-virus-associated liver cirrhosis (n = 34). Single explant tumors were found in 29 patients; the mean maximal tumor size was 2.1 ± 0.9 cm (range: 0.8-4.0). No patients showed microvascular invasion. The median level of alpha-fetoprotein was 12 ng/mL (range: 1-1160). The 1 patient who showed a recurrence at 20 months remains alive more than 6 years after adrenalectomy and repeated pulmonary metastasectomy. The 5-year HCC recurrence rate was thus 2.1%. There were 2 late mortalities, each due to graft failure and recurrent gastric cancer. The overall patient survival rate was 97.3% at 5 and 92.7% at 10 years. CONCLUSIONS: The results of this study revealed that the loss of tumor viability induced by pretransplant neoadjuvant treatment definitely decreased the risk of post-transplant HCC recurrence. Therefore, patients with nonviable HCC can be regarded as members of a superselect group with minimal risk for HCC recurrence, and may be exempted from routine HCC screening.

A pilot study on the safety and efficacy of generic mycophenolate agent as conversion maintenance therapy in stable liver transplant recipients.

PURPOSE: The patent covering mycophenolate mofetil (MMF) in Korea has expired and, thus, several generic MMF agents are now commercially available. The supply of Cellcept (Roche Korea) was interrupted at the end of 2011, so it was inevitable that a generic MMF would be used instead. During this period, we performed a prospective pilot study to examine the safety and efficacy of a generic mycophenolate agent (Myconol: Hanmi Pharmaceutical, Seoul Korea) for use as conversion maintenance therapy in stable liver transplantation (OLT) recipients. METHODS: OLT recipients, who were treated with MMF on an outpatient basis from January 2012 to March 2012, attended follow-up interviews conducted. The patients had undergone OLT ≥ 2 years before the study, had tolerated Cellcept, and showed stable liver function. Fifty-three patients were followed up for more than 3 months after conversion to the same dose of Myconol. RESULTS: After conversion to Myconol, 6 patients (11.3%) experienced new side effects, which disappeared when they reverted to Cellcept (n = 5) or stopped taking Myconol medication (n = 1). The side effects associated with Myconol included gastrointestinal symptoms (indigestion and diarrhea; n = 3), skin eruptions (n = 1), pruritus (n = 1), and insomnia (n = 1). The mean mycophenolic acid levels were 1.71 ± 0.88 µg/mL for Cellcept and 1.83 ± 0.91 µg/mL for Myconol, which showed a strong correlation (r(2) = 0.92, P < .001). CONCLUSIONS: Myconol showed similar pharmacokinetics to those of Celcept, but a small proportion of patients experienced agent-specific side effects; therefore, patients should be closely monitored when taking Myconol. Also, further studies, with a greater number of patients, are required to identify the full spectrum of drug-associated side effects.

Long-term outcome of liver transplantation for combined hepatocellular carcinoma and cholangiocarcinoma.

PURPOSE: Combined hepatocellular carcinoma (HCC) and cholangiocellular carcinoma (CCC) is a rare pair of intrahepatic malignancies. Differential diagnosis among combined HCC-CCC, HCC, or CCC can be difficult; thus malignancies other than ordinary HCC are occasionally encountered unexpectedly in explanted liver specimens. The present study analyzed the long-term outcomes of liver transplantation (OLT) among patients with HCC-CCC. METHODS: Between January 1999 and December 2009, we performed 2137 adult OLT at our institution including 15 cases of pathologically confirmed HCC-CCC, who all underwent OLT with a pretransplant diagnosis of HCC. We reviewed retrospectively the medical records of these 15 patients. RESULTS: Their mean age was 58.9 ± 7.2 years. The median preoperative alpha-fetoprotein level was 32.6 ng/mL. Fourteen patients underwent living donor and one deceased donor OLT. The Milan criteria were met in 12 cases. A single tumor was identified in 8 and multiple lesions in 7 patients. The maximal tumor diameter was 2.9 ± 1.7 cm. Seven patients experienced tumor recurrences: including 6 within the first 12 months. All of the patients who experienced recurrences died at a median 4 months after that diagnosis. The overall patient survival rates were 66.7% at 1 year and 60.0% at 3 and 5 years. Disease-free patient survival rates were 60.0% at 1 year and 53.3% at 3 and 5 years. CONCLUSIONS: Patients with combined HCC-CCC showed a high rate of early recurrences, particularly within the first year.

Analysis of S gene mutation of the hepatitis B virus in adult liver transplant recipients showing resistance to hepatitis B immunoglobulin therapy.

BACKGROUND: A considerable proportion of recipients of liver transplantations who are presented hepatitis B immunoglobulin (HBIG) monotherapy for hepatitis B virus (HBV) prophylaxis develop HBIG resistance. In this study, we investigated the mutation patterns in the major hydrophilic region (MHR) of amino acid sequences 100 to 160. METHODS: Using the gene sequence analyzer for amino acid sequences 0 to 226 in the S/pre-S region we analyzed blood samples of 15 patients showing HBIG resistance after high-dose HBIG prophylaxis. RESULTS: Various mutations in the MHR were observed in 14/15 samples: Gly145Arg mutation in 8/13 Adr subtype and 1/2 Ayw subtype samples (60%). The next most common mutation was Gly165Trp in 8/13 Adr subtype but neither of 2 Ayw subtype samples (53.3%). Concurrent antiviral resistance was noted in 5 patients: lamivudine (n = 5), or entecavir (n = 3), but not adefovir, suggesting the occurrence of simultaneous, antiviral cross-resistances. Two patients underwent retransplantation due to the progression of HBV infection despite vigorous antiviral therapy. At diagnosis of HBV recurrence, the mean HBV DNA load was 6.5 × 10(6) copies/mL; 4 patients showed paradoxical coexistence of anti-HBs and HBsAg. Currently, 2 subjects show low-level HBV DNA replication in peripheral blood, although the other 12 had no DNA replication after prolonged antiviral therapy. CONCLUSIONS: This study suggested that various mutations in the "a" determinant were associated with HBIG resistance. Since treatment failure to rescue antiviral therapy was often associated with delayed detection of HBV recurrence rather than concurrent antiviral resistance, frequent HBV surveillance using more sensitive screening tests, such as HBeAg and HBV DNA polymerase chain reaction assay, seems to be mandatory.

Clinical outcomes of Pneumocystis carinii pneumonia in adult liver transplant recipients.

PURPOSE: Pneumocystis carinii pneumonia (PCP) is an opportunistic infection associated with morbidity and mortality in solid-organ transplant recipients. We retrospectively assessed the characteristics and outcomes of liver transplant (OLT) recipients with PCP compared with those of patients with severe non-P carinii pneumonia (non-PCP) who required intensive care with mechanical ventilation. METHODS: During the 2-year period between January 2008 and December 2009, 43 adult OLT recipients had severe pneumonia requiring mechanical ventilation; of these, 8 (19%) had PCP. During this period, routine antibiotic prophylaxis was administered for the first 6 months after OLT. RESULTS: The median period from OLT to development of PCP was 9.5 months (range, 1-67); the 1-year incidence was 0.9%. The 6 and 6 to 12-month incidences of non-PCP were 4.2% and 0.3%, respectively, and those of PCP were 0.3% and 0.6%, respectively. Four of 8 patients (50%) in the PCP group had a recent history of a rejection episode. PCP was associated with a higher incidence of prior antirejection treatment. There were no significant differences between PCP and non-PCP groups in age, gender, preoperative Model for End-stage Liver Disease score, primary diagnosis, graft type, and total number of rejection episodes. CONCLUSIONS: These results indicate that the risk of PCP in OLT recipients is closely related to strong immunosuppressive treatment for acute cellular rejection episodes, suggesting the importance of PCP prophylaxis in these patients. Because most patients developed PCP at around 1 year, it may be advisable to prolong routine post-OLT PCP prophylaxis for 12 months, especially among patients receiving antirejection treatment.

Post-transplant assessment of consciousness in acute-on-chronic liver failure patients undergoing liver transplantation using bispectral index monitoring.

PURPOSE: Deterioration of consciousness is a critical situation for liver transplantation (OLT) recipients. The bispectral (BIS) index based on electroencephalographic parameters, is primarily used to monitor the depth of unconsciousness. The present study sought to assess the usefulness of posttransplant BIS index to monitor acute-on-chronic liver failure patients. METHODS: This 1-year retrospective study of 28 adult patients with acute-on-chronic liver failure was performed from July 2011 to June 2012, using post-transplant BIS monitoring. RESULTS: The mean patient age was 51 ± 8 years. Their mean pretransplant Child-Turcotte-Pugh score was 12.3 ± 1.4, and the mean Model for End-stage Liver Disease score, 36.4 ± 5.9. After OLT, the mean initial Glasgow Coma Scale (GCS) score and BIS index were 3.4 ± 1.7 and 43.5 ± 9.1, respectively. After 6 hours the mean GCS and BIS values rose to 8.6 ± 4.0 and 52.4 ± 10.3 and after 12 hours to 9.7 ± 3.4 and 61.3 ± 15.7 respectively. Eye opening in response to a voice occurred at a mean of 8.9 ± 6.7 hours after arrival in the intensive care unit regardless of graft function. The mean GCS and BIS values were 10.6 ± 2.8 and 69.1 ± 13.5, respectively. The endotracheal tube was removed after a median of 140 hours; 9 patients required a tracheostomy. Among them 2 died within the first 3 months after OLT. CONCLUSIONS: BIS monitoring is a noninvasive, simple, easy-to-interpret method to measure consciousness among patients intubated with an endotracheal tube.

Clinical outcome of idiopathic hepatic parenchymal infarct following living donor liver transplantation.

PURPOSE: The aim of the present study was to examine the clinical course of nonvascular hepatic ischemia following adult living donor liver transplantation (LDLT). METHODS: This retrospective study reviewed the medical records of 1782 patients who underwent LDLT from January 2003 to September 2010. Nine subjects (0.5%) suffered idiopathic hepatic parenchymal infarcts (IHPI) classified according to the morphology and extent of the infarcted area as peripheral or central. RESULTS: Increased levels of liver enzymes were observed in all IHPI patients. Liver cell damage closely correlated with the extent of the infarcted area. Most patients with peripheral-type IHPI showed favoarable spontaneous recovery, occasionally requiring liver support with plasmapheresis or a prolonged period. By contrast, 2 patients with central-type IHPI died due to progressive expansion of the infarcted area with subsequent graft failure. CONCLUSIONS: In the present study the incidence of IHPI following LDLT was 0.5%. The severity of the infarct depended upon its location and size; central-type IHPI showed a worse prognosis. Thus, special attention should be paid to patients showing a central-type infarction.

Computational simulation-based vessel interposition reconstruction technique for portal vein hypoplasia in pediatric liver transplantation.

BACKGROUND: To enhance the technical feasibility of portal vein (PV) interposition grafting for pediatric PV hypoplasia, we performed a computational simulation to establish a customized surgical technique allowing a secure anastomosis of an iliac vein graft to a severely hypoplastic PV stump. METHODS: Based on the literature and on our own experience with reconstruction of PV hypoplasia, we devised three types of recipient PV stump preparations and three types of interposition vein grafts, yielding five technically feasible combinations. RESULTS: The computational simulation model for PV reconstruction using an interposition vein graft revealed the most feasible combination to be a sequential inverted-T incision to the confluence of the superior mesenteric vein and splenic vein with a longitudinal slit in the transverse vein graft end, the technical feasibility was validated by an artificial suture model. This reconstruction was clinically applied to treat a 7.2-kg 10-month-old female patient with biliary atresia and a severely hypoplastic PV. The PV reconstruction was successful; the patient recovered uneventfully. CONCLUSIONS: We have presented a simplified surgical technique for PV interposition that is applicable to pediatric PV hypoplasia, which also appears to be a feasible option for pediatric liver transplantation.

Role of plasmapheresis as liver support for early graft dysfunction following adult living donor liver transplantation.

BACKGROUND: Severe early graft dysfunction has been occasionally encountered following adult living donor liver transplantation (LDLT). We have assessed the effectiveness of plasmapheresis (PP) as liver support for LDLT recipients with severe early graft dysfunction. METHODS: Of the 789 adult LDLTs performed between January 2007 and December 2009, 50 patients (6.3%) underwent PP as a supportive measure during the first month. RESULTS: The mean time from LDLT to start of plasmapheresis was 11.2 ± 6.8 days (range 2-28). The 50 patients underwent 517 sessions of PP, or a mean of 10.3 ± 6.8 sessions per patient, over a mean 21.6 ± 9.4 days. Thirty-four patients (68%) required concurrent hemodiafiltration. Mean serum total bilirubin concentration before PP was 16.2 ± 6.7 mg/dL, peaking at 20.3 ± 7.9 mg/dL during PP, and decreasing to 13.4 ± 5.4 mg/dL 1 week after completion of PP (P < .001 compared with before PP). Except for prothrombin time, no other biochemical parameter was significantly altered by PP. There were no serious complications related to PP. Of the 50 patients, 17 (34%) died soon or a few months after PP. The 6-month graft survival rate after completion of PP was 66%; the overall 1-year patient survival rate was 64.0%. CONCLUSION: PP appeared to have beneficial effects for LDLT recipients with severe early graft dysfunction, namely total bilirubin concentrations greater than 10 mg/dL.

Effect of pulmonary support using extracorporeal membrane oxygenation for adult liver transplant recipients with respiratory failure.

BACKGROUND: Adult liver transplantation (OLT) recipients occasionally show serious acute cardiopulmonary dysfunction, requiring intensive care. We assessed the role of extracorporeal membrane oxygenation (ECMO) support in adult recipients facing acute pulmonary failure and refractory to conventional mechanical ventilation and concurrent nitric oxide gas inhalation. METHODS: From January 2008 to March 2011, 18 adult OLT recipients at our institution required ECMO support: 12 due to pneumonia and 6 to adult respiratory distress syndrome. Their mean age was 55.7 ± 6.9 years and mean Model for End-stage Liver Disease score, 24.8 ± 8.5. Twelve patients had undergone living donor and six deceased donor OLT. RESULTS: A venovenous access mode and concurrent continuous venovenous hemodiafiltration were used in all patients. There were no procedure-related complications. Eight patients (44.4%) were successfully weaned from ECMO upon the first attempt after a mean support of 11.9 ± 6.1 days, but the other 10 died due to overwhelming infection. Univariate analysis revealed no significant pre-ECMO risk factor for treatment failure but C-reactive protein concentration at the time of ECMO differed significantly among patients who did versus did not survive after ECMO. CONCLUSIONS: ECMO as rescue therapy may be a final therapeutic option for OLT recipients with refractory pulmonary dysfunction who would otherwise die due to hypoxemia from severe pneumonia or adult respiratory distress syndrome.

Incidence and management of postoperative abdominal bleeding after liver transplantation.

PURPOSE: To assess the incidence and management of postoperative abdominal bleeding after orthotopic liver transplantation (OLT) and to identify risk factors for abdominal bleeding. METHODS: We retrospectively reviewed the medical records of 1039 patients who underwent OLT at our institution from January 2008 to December 2010 seeking to identify subjects with posttransplantation abdominal bleeding, defined as any hemorrhage requiring radiologic intervention or laparotomy within the first month. RESULTS: Among the 1039 patients, 94 (9%) showed abdominal bleeding, occurring at a mean of 6.1 days (range, day 1 to 21 days). Active bleeding was controlled by endovascular interventional techniques (n = 37; 39%), by surgical ligation or vascular reconstruction (n = 43; 46%), or by sequential combinations of endovascular intervention and surgery (n = 14; 15%). The most frequent bleeding sites for radiologic intervention were the right inferior phrenic artery (n = 14), right and left epigastric arteries (n = 7), intercostal artery (n = 5) and right renal capsular artery (n = 4). The most frequent bleeding sites requiring laparotomy were the hepatic artery (n = 9), diaphragm (n = 8), inferior vena cava (n = 5), abdominal drain insertion site (n = 4), portal vein anastomosis site (n = 4), abdominal wall (n = 3), liver graft cut surface (n = 3), hilar plate (n = 3), and greater omentum (n = 3). Bleeding episodes were associated with greater patient age and increased intraoperative blood loss. CONCLUSIONS: The risk of bleeding from coagulopathy and iatrogenic injury is high during the early posttransplantation period. This risk of bleeding can be minimized by meticulous surgical dissection and bleeding control.

De novo malignancies after liver transplantation: incidence comparison with the Korean cancer registry.

PURPOSE: De novo malignancy is not uncommon after liver transplantation (OLT). We have compared the incidence of novo malignancy following OLT with those among the general Korean population. METHODS: Between January 1998 and December 2008, 1952 adult OLT were performed, including 1714 living donor and 238 deceased donor grafts whose medical records were retrospectively reviewed. RESULTS: Among the 1952 patients, 44 (2.3%) showed de novo malignancies after a mean posttransplant period of 41 months. Among the 14 types of malignancy the most frequent was stomach cancer (n = 11; 25.0%), colorectal cancer (n = 9; 20.5%), breast cancer (n = 4; 9.1%), and thyroid cancer (n = 3; 6.8%). These patients underwent aggressive treatment, including surgery, chemotherapy, and radiotherapy, except for one patient with an aggressive primary liver cancer. Over a mean follow-up of 45 months after diagnosis of de novo malignancy, 13 patients (29.5%) died; the overall 3-year patient survival rate was 67.5%. The relative risk of malignancy following OLT was 7.7-fold higher in men and 7.3-fold higher in women than the Korean general population. CONCLUSIONS: OLT recipients must be checked periodically for de novo malignancy throughout their lives, especially for cancers common in the general population.

Clinical value of preoperative coronary risk assessment by computed tomographic arteriography prior to adult living donor liver transplantation.

PURPOSE: Patients with advanced liver diseases are at increased risk of cardiovascular events, resulting in a higher incidence of cardiac complications following liver transplantation (OLT). We assessed the clinical value of computed tomographic coronary arteriography (CTCAG) as a routine preoperative cardiac evaluation test in adult patients scheduled for living donor OLT (LDLT). METHODS: This single-center, prospective, observational study evaluated 247 adult patients being assessed for LDLT from April 2010 to March 2011. CTCAG was performed in patients with all-negative findings on routine cardiac workup, including thallium single photon emission computed tomography (SPECT). RESULTS: Of the 247 patients evaluated, 27 (10.9%) showed abnormal findings on CTCAG, with 18 (7.3%) showing mild to moderate involvement of one vessel; 7 (2.8%), two-vessel; and 2 (0.8%), three-vessel involvement. Coronary artery calcification was identified in patients with significant coronary artery stenosis. No adverse events occurred after CTCAG. Noticeable hypotensive episodes during LDLT surgery occurred in 5% of patients, mostly related to massive bleeding or postperfusion syndrome. During the first 3 months after LDLT, 3% of patients showed stress cardiomyopathy, but all recovered with supportive care. CONCLUSIONS: The poor general medical condition of LDLT candidates and the diagnostic accuracy of CTCAG suggest that this test should be included in the routine pretransplant cardiac workup, along with thallium SPECT, for these patients.

Right gastroepiploic artery is the first alternative inflow source for hepatic arterial reconstruction in living donor liver transplantation.

BACKGROUND: Sufficient arterial flow after living donor liver transplantation (LDLT) is closely related to graft survival and prevention of postoperative complications. However, some unfavorable hepatic arterial conditions in recipients preclude reconstruction, requiring alternative stumps. We have used the right gastroepiploic artery (RGEA) as a first alternative for hepatic inflow. METHODS: From January 2006 to December 2008, we performed 754 LDLTs including 28 cases of RGEA among hepatic arterial anastomoses. The arterial anastomosis was performed by an single surgeon under 859 a microscope using an end-to-end interrupted suture technique. RGEA was mobilized over 15 cm from the greater curvature of stomach and greater omentum. RESULTS: The indications for RGEA use included severe hepatic arterial injury from previous transarterial chemoembolization (n=14), need for additional arterial flow in dual-grafts LDLT (n=13), poor blood flow from the recipient hepatic artery (n=3), and arterial injury during hilar dissection (n=3). The mean diameter of the isolated RGEA was 2.0±0.2 mm (range: 1.0-2.5). Most hepatic arterial anastomoses were performed with a significant size discrepancy of more than twofold. All reconstructed hepatic arterial flowes showed good; no complication was identified during the mean follow-up period of 56 months to date. CONCLUSIONS: Using RGEA as an alternative arterial inflow is a simple, reliable procedure for situations of inadequate recipient hepatic or multiple graft arteries.

Long-term outcomes of portal Y-graft interposition for anomalous right portal veins in living donor liver transplantation.

BACKGROUND: Anomalous portal vein (PV) branching in living donor livers is not uncommon and usually leads to double PV orifices of the right lobe grafts. We have assessed the long-term outcomes of portal Y-graft interposition for adult living donor liver transplantation (LDLT). METHODS: We retrospectively assessed the outcomes of 79 right-lobe LDLTs using portal Y-graft interposition among the 2001 adult LDLTs performed at our institution from January 2002 to December 2010. RESULTS: Donor PV types were type III except for one case of type II. Sources of Y-grafts were recipient autologous PV in 76 LDLTs, fresh iliac vein allografts in two, and patch plasty using recipient greater saphenous vein in one. Detailed procedures included a portal Y-graft resection with Y-limbs, corner stay sutures, tying of suture materials under direct mechanical dilatation, and direct edge-to-edge anastomosis to the recipient remnant main PV. Early PV stenting was necessary in five patients (6.3%) due to stenosis or buckling deformity. During a mean follow-up of 42 months, all PVs remained patent until patient death or censoring. Overall 1-, 3-, and 5-year patient survival rates were 93.6%, 88.3%, and 85.5%, respectively. None of the 79 donors experienced major complications requiring reoperation or therapeutic intervention. CONCLUSIONS: Due to their technical feasibility and excellent long-term outcome, portal Y-graft interposition should be considered a standard procedure for reconstruction of right-lobe grafts with double PV orifices.

Standardization of modified right lobe grafts to minimize vascular outflow complications for adult living donor liver transplantation.

BACKGROUND: After >2000 adult living donor liver transplants (LDLTs), we observed minimization of the complication rate using case-by-case modification of venous outflow reconstruction in right liver graft (RLG), standardization seeking intend to provide a hemodynamic- based, regeneration-compliant hepatic outflow reconstruction. METHODS: We retrospectively examined 100 consecutive adult LDLT using modified RLG before and after application of RLG standardization to compare the 6-month incidences of vascular outflow complications. RESULT: The right hepatic vein stenting rate for first 6 months was 5% in the customized group and 1% in the standardized group (P=.212). The middle hepatic vein stenting rate for first 6 months was 9% in the customized group and 4% in the standardized group (P=.373). The inferior right hepatic vein stenting rate for first 6 months was 12.8% in the customized group and 7.1% in the standardized group (P=.472). The overall 6-month patient survival rate was 94% in the customized group and 95% in the standardized group (P=.867). The overall incidence of significant RLG venous outflow complications was 19% in the customized group and 8% in the standardized group (P=.023). CONCLUSION: Standardization as a universal graft model seemed to be more effective and feasible than conventional graft customization requiring individualized case-by-case modification.

Safety of ultra-rapid intravenous infusion of hepatitis B immunoglobulin in liver transplant recipients.

PURPOSE: To evaluate the safety of institutional protocol for ultra-rapid hepatitis B immunoglobulin (HBIG) infusion (10,000 IU in 30 minutes) for hepatitis B virus prophylaxis in adult liver transplant recipients. METHODS: In this case-controlled study, prospectively recruited liver transplant recipients received ultra-rapid infusions of HBIG (10,000 units in 30 minutes) for 6 months. The historical control group consisted of patients who had received 1-hour HBIG infusions (conventional rapid infusion) for the precedent 6 months. RESULTS: We found that 1472 patients had received 5744 ultra-rapid HBIG infusions, whereas 1343 patients had received 5200 conventional rapid HBIG infusions. Adverse side-effects were observed after 7 (0.13%) and 9 (0.16%) infusions, respectively (P = .763). The number of infusions per month increased significantly, from 878 ± 34 before the introduction of ultra-rapid infusion to 957 ± 29 afterwards (P < .001), an increase of 10.5%. The maximal capacity of HBIG infusions per day in the outpatient clinic increased from 53 for conventional rapid infusion to 65 for ultra-rapid infusion, without expansion of the outpatient facility or equipment. CONCLUSIONS: Nearly all adult liver recipients able to tolerate 1-hour infusions of HBIG can also tolerate ultra-rapid infusions well. Thus, it seems to be reasonable to perform ultra-rapid infusion protocol widely for patient convenience.