Does laparoscopic-guided transversus abdominis plane block have an effect on postoperative pain and recovery after sleeve gastrectomy?

OBJECTIVE: Postoperative pain management is thought to have an effect on patient comfort, morbidity, and mortality after bariatric surgery. Local anesthetic agents are frequently used for this purpose. Local anesthetics can be used in many different ways. In this study, we aimed to investigate the effect of transversus abdominis plane (TAP) block on postoperative pain by laparoscopic method. PATIENTS AND METHODS: A prospective randomized clinical trial was performed. While TAP block was applied to one group with bupivacaine, no action was taken for the other group. Postoperative analgesia was given to both patient groups with the "patient-controlled analgesia (PCA)" device. Demographic, operational, and postoperative clinical and pain data of the patients were recorded. RESULTS: TAP block and non-TAP block groups consisted of 30 patients each. Visual analog scale (VAS) scores of the patients at 6, 12, and 24 hours were lower in the TAP group compared to the non-TAP group (p=0.015, 0.018, 0.04, respectively). According to the PCA device data, the analgesic requirement was lower in the TAP group at 6, 12, and 24 hours (p <0.001). Rescue analgesia was required more in the non-TAP group (p=0.04). There was no statistically significant difference between the two groups in terms of gas discharge time (p=0.102), stool discharge occurred earlier in the TAP group (p=0.02). Oral intake times (p=0.554) and length of stay hospital (p=0.551) were similar. CONCLUSIONS: Laparoscopic TAP block using bupivacaine can be safely administered in morbidly obese patients and reduces postoperative analgesic requirements. Thus, side effects that may develop secondary to the use of analgesics are avoided.

Totally laparoscopic resection and extraction of specimens via transanal route in synchronous colon and gastric cancer.

INTRODUCTION: Synchronous colon and gastric cancer is a rare clinical entity. In the present case, it is aimed to show that in a patient with synchronous colon and gastric cancer, laparoscopic resection can be safely performed and both specimens can be delivered through a natural orifice. In our knowledge, this is the first example showing the delivery of the gastric resection specimen through the anus in a human being. CASE REPORT: Sixty-six years old male patient with an upper gastrointestinal bleeding and obstruction symptoms was admitted to our department and the evaluation revealed an advanced stage gastric and a synchronous colon cancer. A laparoscopic palliative subtotal gastrectomy with a subtotal colectomy was performed. All anastomoses were performed intracorporeally and colectomy and subtotal gastrectomy specimens were successfully delivered via trans-anal route without any difficulty. Despite major abdominal organ resections, the patients required quite less analgesics in the postoperative period. DISCUSSION: Specimen extraction through the natural orifices eliminates the need and problems of performing additional abdominal incisions to the patients which also leads to reduced postoperative pain. Synchronous surgical procedures do not prevent the natural orifice surgery.

Living Donor Re-transplantation for Repeated Acute Liver Failure.

Emergency liver transplantation (LT) for acute liver failure (ALF) is a life-saving treatment. Occurrence of this situation in the same patient twice is very rare. Herein, we describe a patient who underwent two emergency LTs for ALF, both from living donors. When she was 26 years old, she underwent a right lobe living donor LT (LDLT) from her sister for ALF due to use of herbal weight loss medications. The next 3 years were uneventful but another ALF developed during a terminal stage pregnancy (37th week). Despite medical treatment, her liver functions worsened, and the baby was delivered by caesarean section. The second time, her brother was the donor and she recovered after the emergency right lobe re-LDLT. Both patient and baby were well at the 2-month follow-up. As far as we know, there is no reported similar case, and we concluded that LDLT is a paramount treatment option for both primary and secondary ALFs.

Success rate of natural orifice specimen extraction after laparoscopic colorectal resections.

PURPOSE: To date, no data have been available to inform which cases are appropriate for natural orifice specimen extraction (NOSE) after laparoscopic colorectal resections (LCRRs). Our aim was to evaluate the success rate and the factors affecting the failure in patients who were scheduled for NOSE after LCRRs. METHODS: Seventy-two consecutive cases that were intended for NOSE after LCRR were enrolled. The transanal route was always chosen as the first option, and when it failed, the transvaginal route was tried in female patients. If both failed, the specimen was judged as unsuitable for NOSE and removed through an abdominal wall incision. Demographic data, surgical indications, resection localization, implemented procedures, incision sites, specimen extraction methods, specimen sizes, and failures of NOSE were recorded. RESULTS: A total of 349 colorectal resections (240 open and 109 laparoscopic) in a 3-year period were examined. The subset of 72 consecutive patients who met the criteria were analyzed. Five cases required a conversion to open surgery during resections. In the remaining 67 patients, NOSE after LCRR was successful in 49 cases (73.1%) but failed in 18 (26.9%). Specimens were extracted from transanal and transvaginal routes in 37 (75.5%) and 12 (24.5%) patients, respectively. The failure rate of NOSE after LCRR was higher in males, in colonic lesions, and in large-sized tumors. The mean sizes of transanal and transvaginal extracted specimens were 3.5 ± 3.1 and 5.4 ± 1.4 cm, respectively (p < 0.05). The mean size of the tumors in the failed cases was 6.5 ± 4.2 cm (p < 0.05). CONCLUSIONS: Approximately 2/3 of the unselected LCRRs were suitable for NOSE. The success rate increased with female gender, small-sized tumors, and rectal resections.

Telescopic Biliary Reconstruction in Patients Undergoing Liver Transplantation With 1-Year Follow-up.

BACKGROUND: Biliary complications are important during liver transplantation because of their effect on recipient and graft survival, incidence, and the long treatment period. These complications are associated with 50% morbidity and 30% mortality rates in recent studies. One of the most important reasons for biliary anastomosis complications is arterial ischemia. We present the results of our telescopic biliary anastomosis technique performed on the mucosa of the main biliary duct. PATIENTS AND METHODS: Fifty-six cases of telescopic biliary reconstruction were performed in 203 patients during 2015. Fifty cases and 52 patients who underwent standard reconstruction were chosen and compared. All patients had been scanned retrospectively. Statistical analyses were conducted with χ2 and Mann-Whitney U tests for the complications that occurred during the first 3 months. A P value <.05 was considered significant. RESULTS: No clinical or demographic differences were detected between the groups. About 90% of both groups were living donor liver transplantation cases. Five (10%) anastomotic leaks occurred in telescopic reconstruction group (n = 50), and 13 (25%) occurred in the standard reconstruction group (n = 52; P < .05). CONCLUSION: The arterial blood supply is better if the biliary anastomosis is made on the mucosal side of the main biliary duct. Early period anastomotic leaks may decrease significantly.

Can Patients Who Develop Cerebral Death in Fulminant Liver Failure Despite Liver Transplantation Be Previously Forseen?

BACKGROUND: The outcome of medical treatment is worse in fulminant liver failure (FLF) developing on acute or chronic ground. Recently, liver transplantations with the use of living and cadaveric donors have been performed in these diseases and good results obtained. In this study, we aimed to present the factors affecting the recovery of cerebral functions after liver transplantation in hepatic encephalopathy (HE) developing in FLF, to identify irreversible patient groups and to prevent unnecessary liver transplantation. METHODS: In Inonu University's Liver Transplant Institute, 69 patients who made an emergency notice to the National Coordination Center for liver transplantation owing to FLF from January 2012 to December 2015 were included in the study. Patients were divided into 2 groups. Group 1 consisted of 52 patients who underwent liver transplantation and recovered normal brain function, and group 2 had 17 patients who underwent liver transplantation and did not recover normal brain function and had cerebral death. All patients were evaluated before surgery for clinical encephalopathy stage, light reflex, and convulsions. Groups were compared and assessed according to age (>40, 10-40 and <10 years), body mass index, etiologic factor, preoperative laboratory values, transplantation type, mortality, and encephalopathy level. Multivariate analysis was done for specific parameters. RESULTS: Prothrombin time (PT), international normalized ratio (INR), and total bilirubin values were significantly different between the groups. There was no significant difference between the groups regarding ammonia and lactate levels. There was a statistically significant difference between the groups regarding sodium and potassium levels from serum electrolytes. However, the averages of both groups were within normal limits. pH and total bilirubin levels were meaningful for multivariate analysis. CONCLUSIONS: HE reversibility, mortality, and morbidity are important in patients with HE who undergo liver transplantation. Therefore, West Haven clinical staging and serum INR, PT, and total bilirubin level may be helpful in predicting the reversibility of FLF patients with HE before liver transplantation. It was determined that West Haven encephalopathy grading is important in determining the reversibility of HE after transplantation in FLF; especially the probability of reversibility of stage 4 HE decreases significantly. High PT and INR levels, hyperbilirubinemia, and serum sodium and potassium concentrations were risk factors for the reversibility of HE in this study.

Retained Foreign Body in Transplanted Liver.

Liver transplantation is a technically complex and long surgical procedure. A large quantity of various materials such as catheters, sutures, needles and clips are frequently used during the procedure. These materials may enter in the liver from the vascular or biliary orifices inadvertently. A 50-year-old patient who had hepatic failure due to HBV underwent a deceased-donor liver transplantation. The deceased donor was a 75-year-old HbsAg(+) man. The recipient had subfebrile fever and leukocytosis post-operatively. A control computed tomography revealed a cuneiform ischemic area, and a foreign body inside the right anterior portal vein branch proximal to this ischemic region. A 10-F Nelaton catheter, 5-cm long, was removed from the portal vein by surgery. Retrospectively, we understood that the portal vein was cut during the back-table procedure and the portal vein catheter was replaced with a larger one for better irrigation. Most probably, the original catheter was cut together with the portal vein, and the tip of the catheter was retained in the portal system and migrated into the liver. As far as we know, such a complication of liver transplantation has never been described previously.

Futility Versus Acceptability of the Use of Grafts Taken From End of Line in the National Organ-Sharing Network.

BACKGROUND: The number of suitable donors for organ transplantation is limited in many countries. This limitation can be overcome with the use of organs removed from marginal donors (expanded-criteria donors [ECDs]). We examined the long-term results of 187 patients who underwent marginal cadaveric liver transplantation in our institution. METHODS: The data of patients who underwent cadaveric liver transplantation from January 2007 to April 2014 were retrospectively reviewed. ECDs were evaluated by considering 19 internationally accepted criteria. The clinical data of recipients including age, clinical status, and Model for End-Stage Liver Disease (MELD) score were also assessed. RESULTS: A total of 287 patients underwent cadaveric liver transplantation. A graft from an ECD was used in 181 (63.06%) patients. The mean MELD score was 18.8. In all, 45 patients (24.86%) underwent transplantations for fulminant liver failure and 136 patients (75.14%) underwent transplantations for other chronic conditions. The majority of donors died of cerebrovascular disease and trauma. Only hypotension requiring inotropic drugs and obesity significantly affected survival. The 90-day and 12-month survival rates of the recipients who received a graft from an ECD were 51.93% and 46.2%, respectively. CONCLUSIONS: The use of ECD allografts immediately and significantly expands the existing donor pool. Because of persistent organ scarcity, pressure to use a greater proportion of the existing donor pool will continue to increase.

Histopathological Examination of Explanted Liver After Transplantation in Patients With Cryptogenic Cirrhosis.

OBJECTIVES: Cryptogenic cirrhosis is a common indication for liver transplantation. Diagnosis is made after exclusion of other causes of cirrhosis. In this study, the aim was to evaluate patients with cryptogenic cirrhosis after histopathological examination of explanted liver. MATERIALS AND METHODS: A retrospective histopathological chart review of 117 patients with cryptogenic cirrhosis who had liver transplantation between November 2009 and June 2014 was performed. Age, sex, operative features, survival rates, and preoperative and postoperative diagnosis were evaluated. RESULTS: During the study period, 123 liver transplantations were performed for these 117 patients. Deceased donor liver transplantations were performed in 23 (18.7%) of the cases. Retransplantations were performed in 5 patients. Median age was 48 years, and female-to-male ratio was 41:76. Hepatosteatosis were observed in 29 patients. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis were observed in 20 (12%) and 9 (7.7%) of these patients, respectively. Autoimmune hepatitis was observed in 2 patients. The definitive cause of cirrhosis was unclear in 68 (58%) of the patients. Incidental malignant and premalignant lesions were observed in 15 patients. CONCLUSIONS: Histopathological examination of the explanted liver after liver transplantation in those patients with cryptogenic cirrhosis may significantly help to diagnose the cause of cirrhosis, such as nonalcoholic steatohepatitis or autoimmune hepatitis, with using the scoring system developed by the International Autoimmune Hepatitis Workgroup. In addition, incidental malignant or premalignant lesions may be observed.

Living Donor Liver Transplantation With Vena Cava Replacement.

OBJECTIVES: This study sought to evaluate the indications, techniques, and results of inferior vena cava (IVC) replacement at living donor liver transplantation (LDLT). MATERIALS AND METHODS: We performed 821 LDLTs and 11 (1.3%) patients required concomitant IVC replacement. We analyzed the indications, replacement materials, and outcomes. RESULTS: Right, left, and left lateral liver lobes were transplanted in 7, 2, and 2 patients, respectively. The indications for IVC replacement were thrombosis/fibrosis in 7 patients (Budd-Chiari 4, hereditary tyrosinemia 1, congenital hepatic fibrosis 1, cryptogenic 1), involvement with mass in 3 patients (Echinococcus alveolaris 2, hepatoblastoma 1) and iatrogenic narrowing at IVC in 1 patient. Cryopreserved grafts (aorta n = 5, IVC n = 4, iliac vein n = 1) or synthetic graft (n = 1) were used for replacements. In 1 patient, hepatic outflow obstruction developed at 39 days and was treated successfully by interventional radiology. There was only 1 hospital mortality (8.9%) that was unrelated to caval replacement (subarachnoid hemorrhage). Of the remaining patients, the caval grafts were patent after a mean 7.7 months of follow-up (range 1 to 17 months). CONCLUSIONS: Although rare, IVC replacement can be necessary at LDLT. Budd-Chiari and E. alveolaris are the main underlying diseases for replacement requirements. Caval replacement with cryopreserved vascular grafts can provide successful short-term and long-term patency.

Circumferential Fence With the Use of Polyethylene Terephthalate (Dacron) Vascular Graft for All-in-One Hepatic Venous Reconstruction in Right-Lobe Living-Donor Liver Transplantation.

Integration of hepatic vein tributaries with a diameter ≥ 5 mm into the drainage system in right-lobe living-donor liver transplantation (LDLT) is of vital importance for graft function. Recently, the most commonly emphasized hepatic venous reconstruction model is the all-in-one reconstruction model. In the final stage of this model that aims to form a common large opening, allogeneic vascular grafts are almost always used to construct a circumferential fence. To date, no other study has reported the use of polyethylene terephthalate (Dacron) vascular graft as a circumferential fence in LDLT. We aimed to present the 1st 4 cases of circumferential fences created with Dacron vascular graft. Four right-lobe grafts weighing 522-1,040 g were used. A polytetrafluoroethylene vascular graft was used for the integration of segment 5 vein and segment 8 vein into the drainage model, whereas a Dacron graft was used to creating a circumferential fence. The patency of hepatic outflow evaluated with the use of multidetector computerized tomography at postoperative day 7. Venous outflow obstruction was not detected in any cases. This study suggested that owing to its flexible structure the polyethylene terephthalate vascular graft can be an alternative to allogeneic vascular grafts in forming circumferential fence.

Influence of Liver Transplantation on Neuropsychiatric Manifestations of Wilson Disease.

OBJECTIVES: This study sought to evaluate the effect of liver transplantation on the neuropsychological manifestations of Wilson disease. MATERIALS AND METHODS: Nine of 42 Wilson disease patients had neuropsychological symptoms before liver transplantation. They were 7 male and 2 female subjects with a median age of 19 years (range 10 to 25). They were analyzed for their preoperative and postoperative hepatic, neurological, and psychological scores described by the Unified Wilson Disease Rating Scale after a mean 36.6 months of follow-up. RESULTS: Preoperative mean Model for End-Stage Liver Disease and Child-Pugh scores were 18.3 (range 15 to 26) and 8.9 (range 6 to 12), respectively. One patient had acute postoperative ischemic stroke unrelated to Wilson disease and was excluded from the statistical analysis. Preoperative and postoperative hepatic, neurological, and psychological scores of the remaining 8 patients were 7.4 ± 2.3 vs 2.4 ± 1.3 (P = .0005), 17.7 ± 11.7 vs 12.7 ± 12.5 (P = .055), and 9.0 ± 1.7 vs 7.0 ± 2.1 (P = .033). CONCLUSIONS: Liver transplantation for Wilson disease can provide some improvement of the neuropsychological symptoms in addition to the hepatic recovery.

Postoperative Pulmonary Complications After Liver Transplantation: Assessment of Risk Factors for Mortality.

BACKGROUND: The aim of this study was to identify the risk factors related to mortality in liver transplant (LT) patients with post-transplantation pulmonary complications. METHOD: Patients who underwent liver transplantation in our clinic between January 2010 and January 2012 were retrospectively reviewed for post-transplantation pulmonary complications. Demographic, clinical, radiologic, and postoperative chart data of 153 patients with pulmonary complications were analyzed using an independent samples Student t test, Pearson's χ(2) test, Fisher's exact test, and Yate's corrected χ(2) test. Mortality was analyzed using a multiple logistic regression model. The best-fit breakpoint resulting in a cut-off value for the variables of interest was determined using ROC curves and the Youden index. RESULTS: The 153 patients with pulmonary complication were divided into 2 groups: mortality (n = 53) and survival (n = 100). Univariate analyses showed significant differences between these 2 groups with respect to MELD score (P = .035), duration of mechanical ventilation (P > .001), pneumonia (P = .01), and endotracheal culture results (P = .001). In the multivariate analysis, hemoglobin (P = .03, odds ratio [OR]: 1.239), MELD score (P = .027, OR: 1.064), duration of mechanical ventilation (P = .003, OR: 1.091), and age (P = .042, OR: 1.001) were significant risk factors for mortality. The best-fit breakpoint analysis yielded cut-off values for hemoglobin (>11.2, sensitivity: 50.9%, specificity: 70%), MELD score (>16, sensitivity: 73.6%, specificity: 42%) and duration of mechanical ventilation (>3, sensitivity: 62.3%, specificity: 76%). CONCLUSION: Advanced age, high hemoglobin level, high MELD score, and long-term mechanical ventilation are significant risk factors for mortality in liver transplant patients with postoperative pulmonary complications.

Using autologous peritoneal graft for portal vein injury due to blunt thoracoabdominal trauma.

BACKGROUND: Autologous vein or prosthetic materials are used as patch or tube graft for portal or caval vein reconstruction after trauma or tumor resection. Preparation of autologous veins requires extra incisions and is time consuming that is crucial especially in trauma patients. This condition adversely affects postoperative morbidity and mortality, particularly in trauma cases. Prosthetic materials may not be available in some centers, and their use is associated with an increased risk of infection. DESCRIPTION OF CASE: A 28-year-old hemodynamically unstable man presented to the emergency room with complete transection of main portal vein, right hepatic artery and common bile duct with tissue defect on hepatoduodenal ligament due to blunt thoracoabdominal trauma. Reconstructing of the portal vein was performed using an autologous peritoneal tube graft. CONCLUSION: Autologous peritoneal graft is a very good option in the treatment of major vascular injuries which can not be repaired with primary suturing. It is also easy to prepare and use, safe, without a need of additional incision, as an alternative to autologous veins and prosthetic materials especially under emergency conditions. Hippokratia 2015; 19 (3): 260-262.

Laparoscopic right colectomy with transvaginal extraction in a patient with prior pancreaticoduodenectomy.

INTRODUCTION: Previous complicated abdominal surgeries such as pancreaticoduodenectomy with large abdominal incisions may keep the surgeons away from major laparoscopic procedures. To the best of our knowledge, there is no published study that shows the feasibility of major laparoscopic surgery in a patient with previous pancreaticoduodenectomy. CASE REPORT: A 68-year-old female (BMI 27 kg/m2, ASA II), was admitted for anemia. Her medical history included an open pancreaticoduodenectomy four years ago for chronic pancreatitis. She had an abdominal Mercedes incision. Computed tomography and colonoscopy showed a 5-cm cecal mass with a histological diagnosis of adenocarcinoma. We performed a totally laparoscopic right hemicolectomy and intracorporeal ileotransverse anastomosis. The specimen was extracted through the vagina. The operating time was 500 minutes and the blood loss was 400 ml. The patient was uneventfully discharged on postoperative day four. CONCLUSIONS: Laparoscopic colon surgery can be feasible and safe despite previous extensive abdominal surgeries such as pancreaticoduodenectomy. Moreover, laparoscopic surgery in these cases can also be completed with intracorporeal anastomosis and specimen extraction through a natural orifice.

Temporary Parenteral Tacrolimus Requirement due to Unexplained Low Through Levels in a Liver Transplant Patient with Short Bowel Syndrome.

An adequate level of tacrolimus in serum should be obtained to prevent acute rejection following liver transplantation. Because of good gastrointestinal absorption of oral tacrolimus, adequate trough levels can be achieved even in patients with short bowel syndrome. Rarely, adequate through levels cannot be obtained by oral administration of the drug for several reasons such as inadequate absorption, having a discordant patient, laboratory error, and/or interactions with other drugs and foods. Here, we described a 16-year-old patient who had undergone massive intestinal resection due to mesenteric torsion 5 years previously and required liver transplantation for cryptogenic cirrhosis. Her remnant small bowel length was 90 cm. After a successful living donor liver transplantation, oral tacrolimus administration resulted in inadequate through levels in some parts of the postoperative period. We checked up all the potential reasons but could not identify any cause. An intravenous tacrolimus including immunosuppressive regimen was temporarily required. She maintained adequate blood levels of tacrolimus by parenteral route for a while; thereafter, oral administration resulted in enough blood drug levels. She was discharged with oral tacrolimus therapy. We concluded that very rarely, adequate blood levels of tacrolimus cannot be achieved by oral administration for unexplained reasons. In such cases, temporary administration of parenteral tacrolimus can be life-saving.

Right-lobe living-donor liver transplantation in adult patients with acute liver failure.

BACKGROUND: Right-lobe living-donor liver transplantation (RLDLT) is an excellent option to reduce donor shortages for adult patients with acute liver failure (ALF). The aim of this study was to evaluate the etiologies and outcomes of 30 consecutive adult patients who underwent emergency RLDLT for ALF. METHODS: Between January 2007 and September 2011, we examined data from medical records of patients with ALF who underwent RLDLT. RESULTS: Their mean age was 32.2 ± 13.05 years. The etiologies of ALF were acute hepatitis B (n = 11; 36.6%), hepatitis A (n = 4; 13.3%), drug intoxication (n = 4; 13.3%), pregnancy (n = 2; 6.7%), hepatitis B with pregnancy (n = 1; 3.3%), mushroom intoxication (n = 1; 3.3%), and unknown (n = 7; 23.3%). The mean hepatic coma grade (Model for End-Stage Liver Disease score) was 34.13 ± 8.72. The 43 (48.7%) postoperative complications were minor (grades I-II) and 44 (51.3%) were major (grades III-V). Reoperation was required in 14 of 30 (47%) recipients (grades IIIb-IVa). Deaths occurred owing to pulmonary (n = 2), cardiac (n = 1), septic (n = 2), or encephalopathic (n = 4) complications. The mean durations of intensive care unit stay and postoperative hospitalization were 3.2 ± 2.3 and 29.5 ± 23 days, respectively. The survival rate was 70%. The mean follow-up duration was 305 days (range, 1-1582). CONCLUSION: Liver transplantation is potentially the only curative modality, markedly improving the prognosis of patients with ALF. The interval between ALF onset and death is short and crucial because of the rapid, progressive multiorgan failure. Thus, RLDLT should be considered to be a life-saving procedure for adult patients with ALF, requiring quicker access to a deceased-donor liver graft and a short ischemia time.

Hepatic artery thrombosis-related risk factors after living donor liver transplantation: single-center experience from Turkey.

AIM: The purpose of this retrospective study is to evaluate the risk factors hepatic artery thrombosis (HAT) after orthotopic liver transplantation (OLT) in a consecutive series from a single center. MATERIALS AND METHODS: Between January 2010 and May 2012, we performed 278 living donor liver transplantations, including 189 males and 89 females. We compared the risk factors between HAT and non-HAT groups according to the following variables: age, gender, body mass index (BMI), graft weight, use of graft, Child-Pugh and model for end stage liver disease score, level of hemoglobin, blood pressure, operation time, blood transfusion, presence of ascites, international normalized ratio (INR) level, and etiology. RESULTS: Eighteen patients, including 15 males and 3 female, had HAT after the operation (mean age, 45.1 years; age range, 22-60 years). There were no pediatric patients in the HAT group. HAT rate was 6.5% in our series. Graft loss and retransplantation due to HAT was 38.7% in a 2-year period. Biliary leakage was observed in 72 (25.8%) living donor liver transplantations; this rate was higher in patients with HAT (n = 8; 44.4%). The infection rate was 50% (n = 9) in the HAT group and was 32.7% (n = 91) in the non-HAT group. Mean INR value was 2.15 in the HAT group and 1.72 in the non-HAT group. When we compared the groups according to use of graft for anastomosis, biliary lekage, infection, and INR value, the differences were statistically significant (P < .05). CONCLUSION: Although the results of OLT have improved over the past years, HAT is still associated with substantial morbidity, high incidence of graft failure, and high mortality rates. The most important findings associated with HAT in our series were found as INR levels, bile leakage, and resistant infections. Use of vascular graft for hepatic artery anastomosis was found to increase HAT risk.