Combined associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) followed by left trisectionectomy and Whipple operation for PNET.

Pancreatic neuroendocrine tumor (PNET) is slow-growing, and account only for 2% of all pancreatic primary tumors. Surgical resection is still the only curative treatment for PNET patients. Unfortunately, most of PNETs was found with unresectable multiple liver metastases and extrahepatic metastasis as their characteristics of non-functional and asymptomatic. With advances in liver surgery in these years, especially combined associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), provide a new curative surgical treatment for PNET with liver metastases patient. Here we report a PNET with multiple liver metastases case underwent ALPPS (followed by left trisectionectomy) and Whipple operation within one-stage.

Comparable Short- and Long-term Outcomes in Living Donor and Deceased Donor Liver Transplantations for Patients With Model for End-stage Liver Disease Scores ≥35 in a Hepatitis-B Endemic Area.

OBJECTIVE: To evaluate if living donor liver transplantation (LDLT) should be offered to patients with Model for End-stage Liver Disease (MELD) scores ≥35. BACKGROUND: No data was available to support LDLT of such patients. METHODS: Data of 672 consecutive adult liver transplant recipients from 2005 to 2014 at our center were reviewed. Patients with MELD scores ≥35 were divided into the deceased donor liver transplantation (DDLT) group and the LDLT group and were compared. Univariate analysis was performed to identify risk factors affecting survival. RESULTS: The LDLT group (n = 54) had younger (33 yrs vs 50 yrs, P < 0.001) and lighter (56 Kg vs 65 Kg, P = 0.004) donors, lighter grafts (627.5 g vs 1252.5 g, P < 0.001), lower graft-weight-to-recipient-standard-liver-volume rates (51.28% vs 99.76%, P < 0.001), shorter cold ischemic time (106.5 min vs 389 min, P < 0.001), and longer operation time (681.5 min vs 534 min, P < 0.001). The groups were comparable in postoperative complication, hospital mortality, and graft survival and patient survival at one year (88.9% vs 92.5%; 88.9% vs 94.7%), three years (87.0% vs 86.9%; 87.0% vs 88.8%), and five years (84.8% vs 81.8%; 84.8% vs 83.3%). Univariate analysis did not show inferior survival in LDLT recipients. CONCLUSIONS: At centers with experience, the outcomes of LDLT can be comparable with those of DDLT even in patients with MELD scores ≥35. When donor risks and recipient benefits are fully considered and balanced, an MELD score ≥35 should not be a contraindication to LDLT. In Hong Kong, where most waitlisted patients have acute-on-chronic liver failure from hepatitis B, LDLT is a wise alternative to DDLT.

Excellent outcomes of liver transplantation using severely steatotic grafts from brain-dead donors.

Liver grafts with macrovesicular steatosis of > 60% are considered unsuitable for deceased donor liver transplantation (DDLT) because of the unacceptably high risk of primary nonfunction (PNF) and graft loss. This study reports our experience in using such grafts from brain-dead donors. Prospectively collected data of DDLT recipient outcomes from 1991 to 2013 were retrospectively analyzed. Macrovesicular steatosis > 60% at postperfusion graft biopsy was defined as severe steatosis. In total, 373 patients underwent DDLT. Nineteen patients received severely steatotic grafts (ie, macrovesicular steatosis > 60%), and 354 patients had grafts with ≤ 60% steatosis (control group). Baseline demographics were comparable except that recipient age was older in the severe steatosis group (51 versus 55 years; P = 0.03). Median Model for End-Stage Liver Disease (MELD) score was 20 in the severe steatosis group and 22 in the control group. Cold ischemia time (CIT) was 384 minutes in the severe steatosis group and 397.5 minutes in the control group (P = 0.66). The 2 groups were similar in duration of stay in the hospital and in the intensive care unit. Risk of early allograft dysfunction (0/19 [0%] versus 1/354 [0.3%]; P>0.99) and 30-day mortality (0/19 [0%] versus 11/354 [3.1%]; P = 0.93) were also similar between groups. No patient developed PNF. The 1-year and 3-year overall survival rates in the severe steatosis group were both 94.7%. The corresponding rates in the control group were 91.8% and 85.8% (P = 0.55). The use of severely steatotic liver grafts from low-risk donors was safe, and excellent outcomes were achieved; however, these grafts should be used with caution, especially in patients with high MELD score. Keeping a short CIT was crucial for the successful use of such grafts in liver transplantation.

A detailed evaluation of cardiac function in cirrhotic patients and its alteration with or without liver transplantation.

BACKGROUND: Cirrhosis has been shown to be associated with left ventricular (LV) myocardial dysfunction, but studies of right ventricular (RV) function in cirrhotic patients compared with controls are scarce. Limited studies have prospectively evaluated the progression of myocardial function in patients with cirrhosis and assessed changes in cardiac function following liver transplantation (LTx). So the aim of the study was to evaluate biventricular myocardial function in cirrhotic patients and its alteration with or without liver transplantation. METHODS: A total of 103 patients with cirrhosis (age 55±7 years, male 75%) were recruited. Conventional and 2-dimensional speckle tracking echocardiography was performed to determine the presence of LV and RV (biventricular) dysfunction. For comparison, 48 matched control subjects were included. Follow-up echocardiography was performed in 41 patients following LTx and in 26 patients who did not undergo LTx. RESULTS: Patients with cirrhosis had biventricular dilatation, increased LV mass, impaired LV diastolic function, and biventricular systolic strain compared with controls. Following LTx, cirrhotic patients had reduced biventricular dilatation, a smaller LV mass, and improved biventricular systolic strain after a mean duration of 18.2±6.6 months. Patients who did not undergo LTx had a further increase in LV mass but no significant change in biventricular dimensions or systolic strain (mean duration of 20.4±8.3 months). CONCLUSIONS: The present study demonstrates that patients with cirrhosis had biventricular dilatation and impaired biventricular systolic strain compared with controls. Following LTx, biventricular dilatation reduced and biventricular systolic strain improved. In contrast, patients who did not undergo LTx experienced a further increase in LV mass.

New insights after the first 1000 liver transplantations at The University of Hong Kong.

BACKGROUND/OBJECTIVE: One thousand liver transplantations have been performed at the only liver transplant center in Hong Kong over a period of 22 years, which covered the formative period of living donor liver transplantation. These 1000 transplantations, which marked the journey of liver transplantation from development to maturation at the center, should be educational. This research was to study the experience and to reflect on the importance of technical innovations and case selection. METHODS: The first 1000 liver transplantations were studied. Key technical innovations and surgical therapeutics were described. Recipient survival including hospital mortality was analyzed. Recipient survival comparison was made for deceased donor liver transplantation and living donor liver transplantation indicated by hepatocellular carcinoma and other diseases. RESULTS: Among the 1000 transplantations, 418 used deceased donor grafts and 582 used living donor grafts. With the accumulation of experience, hospital mortality improved to < 2% in the past 2 years. In the treatment of diseases other than hepatocellular carcinoma, living donor liver transplantation was superior to deceased donor liver transplantation, with a 10-year recipient survival around 90%. CONCLUSION: Transplant outcomes have been improving consistently over the series, with a very low hospital mortality and a predictably high long-term survival.

Outcomes of endo-radiological approach to management of bile leakage after right lobe living donor liver transplantation.

BACKGROUND AND AIM: Bile leakage is a major complication after right lobe living donor liver transplantation (RLDLT). It can result in significant morbidities and, occasionally, mortalities. Endo-radiology is a non-surgical means that has been used to manage this complication. This study reviews the outcomes of the endo-radiological approach to the management of bile leakage after RLDLT with duct-to-duct anastomosis (DDA) at a high-volume center. METHOD: A retrospective study was conducted on all adult patients who received RLDLT at our center between January 2001 and December 2013. There were 496 RLDLTs performed during the study period. Only patients who had DDA as the only bile duct reconstruction method were included in the study. RESULTS: Twelve (3.7%) out of the 328 study subjects developed bile leakage after RLDLT. Six out of these 12 patients were successfully treated with the endo-radiological approach without the need for laparotomy. They had endoscopic retrograde cholangiography with stenting followed by percutaneous drainage of biloma. One of the 12 patients died from recurrence of hepatocellular carcinoma 37 months after transplantation. The remaining 11 patients are all alive. CONCLUSION: The endo-radiological approach should be the first-line management for bile leakage for selected patients with DDA as the bile duct reconstruction method.

Clinical factors affecting rejection rates in liver transplantation.

BACKGROUND: With improvements in survival, liver transplant recipients now suffer more morbidity from long-term immunosuppression. Considerations were given to develop individualized immunosuppression based on their risk of rejection. METHOD: We retrospectively analyzed the data of 788 liver transplants performed during the period from October 1991 to December 2011 to study the relationship between acute cellular rejection (ACR) and various clinical factors. RESULTS: Multivariate analysis showed that older age (P=0.04, OR=0.982), chronic hepatitis B virus infection (P=0.005, OR= 0.574), living donor liver transplantation (P=0.02, OR=0.648) and use of interleukin-2 receptor antagonist on induction (P<0.001, OR=0.401) were associated with fewer ACRs. Patients with fulminant liver failure (P=0.004, OR=4.05) were more likely to develop moderate to severe grade ACR. CONCLUSIONS: Liver transplant recipients with older age, chronic hepatitis B virus infection, living donor liver transplantation and use of interleukin-2 receptor antagonist on induction have fewer ACR. Patients transplanted for fulminant liver failure are at higher risk of moderate to severe grade ACR. These results provide theoretical framework for developing individualized immunosuppression.

Outcomes including liver histology after liver transplantation for chronic hepatitis B using oral antiviral therapy alone.

The outcomes of hepatitis B virus (HBV)-related hepatitis after liver transplantation (LT) without hepatitis B immune globulin (HBIG) is not well documented. This study aims to determine the outcomes of chronic hepatitis B (CHB) patients using an HBIG-free regimen. All biopsies performed 3 months or more after LT in consecutive CHB patients transplanted from 2003 to 2012 were reviewed. None of the patients received HBIG. Results of all liver histologies were reviewed to determine the cause of graft dysfunction. Of the 435 patients transplanted during this period, 263 liver biopsies were performed in 144 patients. Thirty-six patients were positive for hepatitis B surface antigen (HBsAg) with undetectable HBV DNA at the time of biopsy, and none had histological evidence of HBV infection. Of the 263 biopsies, 44 (17%) had evidence of fibrosis. There was a significantly higher rate of fibrosis in those with large duct obstruction compared to those without (51% versus 9%, respectively; P < 0.001). Of the 291 patients without a liver biopsy during the same period, 43 were HBsAg+. Seven patients had evidence of virological rebound, of whom 6 had evidence of rtM204V/I mutation and 1 had recurrence of hepatocellular carcinoma with low-level rebound and wild-type virus. In conclusion, for patients without virological rebound, positive serum HBsAg was not associated with histological evidence of HBV-related hepatitis after LT. To prevent virological rebound, nucleos(t)ide analogues with higher barriers to resistance should be used.

Durability of small-for-size living donor allografts.

Our aim was to study the long-term outcomes of living donor liver transplantation using small-for-size (SFS) grafts. From July 2002 to July 2009, 233 patients received a right liver graft with a middle hepatic vein from a living donor in our center. Recipients were stratified according to the graft weight to recipient standard liver volume (GW/SLV) ratio into 4 groups: >50% (n = 89), >40% to 50% (n = 85), >35% to 40% (n = 38), and ≤ 35% (n = 21). They were compared in terms of graft survivals, biliary stricture rates, renal function in terms of estimated glomerular filtration rate (eGFR), platelet counts, and graft function in terms of serum bilirubin and international normalized ratio (INR). The 5-year graft survivals for patients with GW/SLV of >50%, >40% to 50%, >35% to 40% and ≤ 35% were 88.8%, 88.2%, 81.5%, and 81.0%, respectively. Transplantation for hepatocellular carcinoma affected graft survivals (P = 0.02), but graft size did not (P = 0.66). There were no differences in frequency of biliary stricture (21.3% versus 17.1% versus 21.1% versus 28.6%; P = 0.75). At each year after transplant, their platelet counts (P = 0.12-0.65), eGFR (P = 0.49-0.91), bilirubin (P = 0.14-0.51), and INR (P = 0.20-0.98) remained comparable. SFS grafts with GW/SLV ≤ 35% and >35% to 40% had comparable long-term outcomes with larger liver grafts. Graft size did not affect long-term graft survivals.

The friendly incidental portal vein thrombus in liver transplantation.

Improved outcomes have been shown in liver transplantation (LT) with portal vein thrombosis (PVT). However, PVT is still discovered incidentally during surgery despite careful preoperative imaging. Data are limited comparing the outcomes of incidental PVT with PVT diagnosed via preoperative imaging before LT. This study aims to compare the overall outcomes of patients with PVT. From 2008 to 2012, 369 patients had LT, and 58 patients with PVT were identified. They were divided into those with non-PVT (group 0; n = 311), preoperatively identified PVT (group 1; n = 28), and incidental PVT (group 2; n = 30). The demographics, characteristics, preoperative assessment, and postoperative outcomes were compared. A survival analysis was also performed. Baseline characteristics and preoperative evaluations of all 3 groups were comparable (P > 0.05) except for Model for End-Stage Liver Disease score, tumor status, platelet levels, and serum bilirubin. A multivariate analysis only showed a high serum bilirubin level to be a predictor of PVT (P = 0.004; odds ratio, 3.395; 95% confidence interval, 1.467-7.861). Postoperative outcomes were also comparable (P > 0.05). Compared to group 2, group 1 had more patients with a Yerdel classification of 3 or 4 with more extensive surgical intervention required (P = 0.02). The survival analysis in all 3 groups was comparable with 5-year survival rate of 87.4%, 84.6%, and 91.8% in group 0, 1, and 2, respectively (P = 0.66). In conclusion, recipients with PVT undergoing LT can have similar outcomes as the non-PVT patients even if PVTs were discovered incidentally. Discovery of incidental PVT only requires thrombectomy with no substantial change of treatment strategy, and the outcome is not adversely affected because most incidental PVTs are of a lower Yerdel grade. Preoperative imaging is useful to identify those with a higher Yerdel grade to allow planning of surgical strategy during transplantation.

Transplantation of a 2-year-old deceased-donor liver to a 61-year-old male recipient.

The suitable size of a graft is a key element in the success of liver transplantation. A small-for-size liver graft is very likely to sustain a significant degree of injury as a result of ischemia, preservation, reperfusion, and rejection. Usually, small-for-size grafts are a concern in living-donor liver transplantation rather than in deceased-donor liver transplantation. Here, we describe the successful transplantation of a liver from a 2-year-old deceased donor to a 61-year-old male recipient who suffered from liver failure related to hepatitis B. No report of successful deceased-donor liver transplantation with discrepancies between donor and recipient age and size to such an extent has been found in the literature. Despite unusually large discrepancies, with effort in minimizing the ischemic time, revised surgical techniques, and strong regenerative power of the "young" graft, the old patient's liver function gradually returned to normal. This again proves that the definition of a "suitable graft" evolves with time and experience.

Radiofrequency ablation versus transarterial chemoembolization for unresectable solitary hepatocellular carcinomas sized 5-8 cm.

OBJECTIVES: This retrospective review was conducted to compare the efficacy of radiofrequency ablation (RFA) with that of transarterial chemoembolization (TACE) in treating large (5-8 cm) unresectable solitary hepatocellular carcinomas (HCCs). METHODS: Patients with large unresectable solitary HCCs primarily treated by RFA or TACE were reviewed. The primary endpoint was overall survival. Secondary endpoints were tumour response, time to disease progression, and treatment-related morbidity and mortality. RESULTS: There were 15 patients in the RFA group. Of these, 12 achieved complete ablation, one had ablation site recurrence, and five developed complications. Median disease-free survival in this group was 13.0 months (range: 2.8-38.0 months). The TACE group included 26 patients, of whom four obtained a partial response, none achieved a complete response, and five developed complications. The median time to disease progression in this group was 8.0 months (range: 1.0-68.0 months). There were no hospital deaths in this series. Median survival was 39.8 months in the RFA group and 19.8 months in the TACE group (P = 0.257). Rates of 1-, 2- and 5-year survival were 93.3%, 86.2% and 20.9%, respectively, in the RFA group and 73.1%, 40.6% and 18.3%, respectively, in the TACE group. CONCLUSIONS: Both RFA and TACE are feasible treatments for large unresectable solitary HCCs. Both modes show comparable rates of complications and longterm survival, but RFA achieves better initial tumour control and results in better short-term survival.

Section 3. Current status of downstaging of hepatocellular carcinoma before liver transplantation.

Liver transplantation (LT) is a well-established option of cure for hepatocellular carcinoma (HCC). Milan criteria is recognized as standard for selection of patients and set the baseline of survival to be achieved. It has been shown that tumor biology including differentiation, vascular invasion, and serum α-fetoprotein (AFP) predict posttransplant recurrence and survival better than morphology. Downstaging by locoregional therapies of HCC before LT, with the response to treatments and progression within observation period, serves as a selection tool rather than modulation of tumor biology. It selects those patients outside standard criteria at presentation but good tumor biology and high chance of good outcome to receive transplantation. The definition of downstaging should be differentiated from neo-adjuvant therapy, and the objectives in surgical and pretransplant candidates also differ.Published studies in this area showed variation in inclusion criteria, downstaging protocol and assessment of successful downstaging. Tumor biology predownstaging and postdownstaging was not incorporated. Posttransplant outcome were not clearly stated with regard to intention-to-treat survival, disease-free survival, and comparison against those originally within criteria. Meta-analysis of these results was impossible. Nevertheless, majority had reasonable protocol and were able to select patients whom likely to have good outcome. At present, there is no evidence that downstaged patients have a poorer prognosis than those presenting within the Milan criteria. Patients with tumors outside Milan criteria should be offered downstaging therapies. Those who are successfully downstaged to within Milan criteria should be eligible to liver transplant as same as those initially fit the criteria. In the last decade, various extended criteria of HCC for LT have been proposed and reported satisfactory survival. That makes downstaging technically unnecessary.To refine and validate the role of downstaging, it needs collaborative and prospective study with significant sample size, adequate preoperative staging, standardized protocol of selection of patients, and approaches to downstaging. Selection criteria should include histopathological data on tumor biology and serum AFP. There should be standardized definition of successful downstaging. Posttransplant disease-free survival should be reported in detail and compared with those who fit the standard criteria initially. A consistent immunosuppressant protocol is important to avoid bias.

Pilot study of high-intensity focused ultrasound ablation as a bridging therapy for hepatocellular carcinoma patients wait-listed for liver transplantation.

The objective of this study was to investigate the outcomes of high-intensity focused ultrasound (HIFU) ablation as a bridging therapy for patients with hepatocellular carcinoma (HCC) who had been wait-listed for deceased donor liver transplantation (DDLT). Adult patients with unresectable and unablatable HCCs within the University of California San Francisco criteria who had been wait-listed for DDLT were screened for their suitability for HIFU ablation as a bridging therapy if they were not suitable for transarterial chemoembolization (TACE). Treatment outcomes for patients receiving HIFU ablation, TACE, and best medical treatment (BMT) were compared. Fifty-one patients were included in the analysis. Before the introduction of HIFU ablation, only 39.2% of the patients had received bridging therapy (TACE only, n = 20). With HIFU ablation in use, the rate increased dramatically to 80.4% (TACE + HIFU, n = 41). The overall dropout rate was 51% (n = 26). Patients in the BMT group had a significantly higher dropout rate (P = 0.03) and significantly poorer liver function as reflected by higher Model for End-Stage Liver Disease scores and higher Child-Pugh grading. Clinically relevant ascites was found in 5 patients in the HIFU group and 2 patients in the BMT group, but none was found in the TACE group (P = 0.01 and P = 0.03, respectively). The TACE and HIFU groups had comparable percentages of tumor necrosis in excised livers (P = 0.35), and both were significantly higher than that in the BMT group (P = 0.01 and P = 0.02, respectively). In conclusion, HIFU ablation was safe even for HCC patients with Child-Pugh C disease. Its adoption increased the percentage of patients receiving bridging therapy from 39.2% to 80.4%. A randomized controlled trial for further validation of its efficacy is warranted.

Retransplantation using living-donor right-liver grafts.

BACKGROUND: This study reviews the outcomes of retransplantation using living-donor right-liver grafts. METHODS: A retrospective study of liver retransplants performed between 1996 and 2013 was conducted. The retransplants were divided into the DD group (with deceased donors) and the LD group (with living donors). Survival outcomes were analyzed. RESULTS: The DD group contained 23 patients and 27 retransplants using whole-liver grafts and the LD group contained 11 patients and 11 retransplants using right-liver grafts. Vascular and biliary complications were the main indications for retransplantation in both groups. The LD group had significantly younger donors, lighter grafts, shorter cold ischemia and longer operations. The two groups were comparable in age, preoperative liver function, warm ischemia, blood loss, transfusion, intensive care unit stay, hospital stay, hospital mortality, complication and graft loss. The 1-year, 3-year and 5-year patient survival rates were 78.3%, 73.7% and 63.8%, respectively, in the DD group. The LD group had the corresponding rates all at 90.9% (P = 0.246). The 1-year, 3-year and 5-year graft survival rates were 74.1%, 65.8% and 61.5%, respectively, in the DD group. The LD group had the corresponding rates all at 90.9% (P = 0.132). CONCLUSION: Excellent long-term survival after retransplantation using living-donor right-liver grafts can be achieved.

Good longterm survival after primary living donor liver transplantation for solitary hepatocellular carcinomas up to 8 cm in diameter.

OBJECTIVES: There is controversy over whether hepatocellular carcinoma (HCC) should be primarily treated with living donor liver transplantation (LDLT) if liver resection (LR) can be effective. This retrospective study was conducted to compare survival outcomes in patients treated with either modality for solitary HCC measuring ≤8 cm in diameter. METHODS: Outcomes in patients with solitary HCC primarily treated by LDLT were analysed. Patients with solitary HCC of similar sizes with or without microvascular invasion primarily treated with LR were selected at a ratio of 6 : 1 for comparison. RESULTS: In-hospital mortality amounted to 0% and 1.3% in the LDLT (n = 50) and LR (n = 300) groups, respectively (P = 0.918). Complication rates were 34% and 20% in the LDLT and LR groups, respectively (P = 0.027). Rates of 1-, 3-, 5- and 10-year overall survival were 98%, 94%, 89% and 83%, respectively, in the LDLT group and 95%, 85%, 76% and 56%, respectively, in the LR group (P = 0.013). Rates of 1-, 3-, 5- and 10-year disease-free survival were 96%, 90%, 87% and 81%, respectively, in the LDLT group and 81%, 64%, 57% and 40%, respectively, in the LR group (P < 0.0001). CONCLUSIONS: Living donor liver transplantation surpassed LR in survival outcomes, achieving a 10-year overall survival rate 1.5 times as high and a 10-year disease-free survival rate twice as high as those facilitated by LR. However, it entailed more complications, in addition to the inevitable risks to the donor.

Low-volume deceased donor liver transplantation alongside a strong living donor liver transplantation service.

BACKGROUND: At our center, living donor liver transplantation (LDLT) is the main workload supported by a strong, mature service. Deceased donor liver transplantation (DDLT) is performed but in small volume. This study aimed to review the results of a low-volume DDLT service alongside a strong LDLT service. METHODS: Consecutive DDLTs for adults performed from 1991 to 2009 were reviewed. The 1st to the 50th DDLTs were categorized as Era I cases, and the rest were Era II cases. The outcomes of the DDLTs were analyzed and compared with those achieved overseas. RESULTS: Eras I and II consisted of 59 and 183 DDLTs, respectively. All donors were brain-dead and heart-beating with a median age of 49 years (range 7-76 years). Among the 242 DDLTS, 30.2 % were on a high-urgency basis and 15.3 % were for hepatocellular carcinoma. The patients had a median model for end-stage liver disease score of 21 (range 6-40), and most (67.8 %) were hepatitis B virus carriers. Before transplantation, 16.1 % of the patients were in the intensive care unit and 30.2 % were in the hospital. The hospital mortality rate dropped from 13.6 % (8/59) during Era I to 3.8 % (7/183) during Era II (p = 0.012). For Era I, the 1-, 3-, and 5-year survival rates were 84.7, 79.7, and 76.3 %, respectively, which improved to 92.9, 89.0 and 87.2 % for Era II (p = 0.026). CONCLUSIONS: The recipient survival of this series compares favorably with contemporary series. It is shown that a low-volume DDLT service alongside a strong LDLT service can have excellent results.

Samaritan donor interchange in living donor liver transplantation.

BACKGROUND: In order to overcome ABO blood group incompatibility, paired donor interchange has been practised in living donor liver transplantation. Liver transplantations using grafts donated by Samaritan living donors have been performed in Europe, North America, South Korea, and Hong Kong. Such practice is clearly on strong biological grounds although social and psychological implications could be far-reaching. Local experience has been satisfactory but is still limited. As few centers have this arrangement, its safety and viability are still being assessed under a clinical trial setting. METHODS: Here we report a donor interchange involving an ABO-compatible pair with a universal donor and an ABO-incompatible pair with a universal recipient. This matching was not only a variation but also an extension of the donor interchange scheme. RESULTS: The four operations (two donor hepatectomies and two recipient operations) were successful. All the two donors and the two recipients recovered well. Such donor interchange further supports the altruistic principle of organ donation in contrast to exchange for a gain. CONCLUSIONS: Samaritan donor interchange certainly taxes further the ethical challenge of donor interchange. Although this practice has obvious biological advantages, such advantages have to be weighed against the potential increase in potential psychological risks to the subjects in the interchange. Further ethical and clinical evaluations of local and overseas experiences of donor interchange should guide future clinical practice in utilizing this potential organ source for transplantation.

A retrospective study on risk factors associated with failed endoscopic treatment of biliary anastomotic stricture after right-lobe living donor liver transplantation with duct-to-duct anastomosis.

OBJECTIVE: This aim of this study is to determine the risk factors in failed endoscopic retrograde cholangiography (ERC). BACKGROUND: Endoscopic treatment is considered the first-line intervention for biliary anastomotic stricture (BAS) after right-lobe living donor liver transplantation with duct-to-duct anastomosis. METHODS: A retrospective study was performed on 287 patients who received right-lobe living donor liver transplantation with duct-to-duct anastomosis. The morphology of BAS was defined according to the shape of the distal side of duct-to-duct anastomosis shown on cholangiogram and was categorized into 3 types: pouched, intermediately pouched, and triangular. All cases of ERC were performed by operating surgeons. RESULTS: Fifty-nine patients (20.6%) had BAS and received ERC and balloon dilatation with or without stenting. The success rate was 73.2%. The median number of sessions needed for successful ERC was 3. In the 15 patients with failed ERC, 4 were successfully treated with percutaneous transhepatic biliary drainage and balloon dilatation and 11 underwent conversion hepaticojejunostomy (6 had external percutaneous transhepatic biliary drainage as a temporizing measure). On multivariate analysis, recipient age [odds ratio (OR): 0.922; 95% confidence interval (CI): 0.85-1.00; P = 0.049], operation time (OR: 1.007; 95% CI: 1.001-1.013; P = 0.025), and morphology of stricture (OR: 6.722; 95% CI: 1.31-34.48; P = 0.022) were independent risk factors associated with failed ERC. The success rates for the 3 types of BAS-pouched, intermediately pouched, and triangular-were 42.9%, 63.6%, and 88.9%, respectively (P = 0.021). Association was found between bile leak and pouched BAS (P = 0.008). CONCLUSIONS: ERC is highly effective in treating BAS. A success rate of 73%, the highest ever reported, has been achieved. Morphology of stricture is associated with outcome of ERC. Radiological or surgical intervention should be considered for patients with pouched BAS after endoscopic treatment fails for the first time.