Aborted living-donor liver transplantation in the real-world setting, lessons from 13 937 cases of Vanguard Multi-center Study of International Living Donor Liver Transplantation Group.

There are exceedingly uncommon but clearly defined situations where intraoperative abortions are inevitable in living-donor liver transplantation (LDLT). This study aimed to summarize the cases of aborted LDLT and propose a strategy to prevent abortion or minimize donor damage from both recipient and donor sides. We collected data from a total of 43 cases of aborted LDLT out of 13 937 cases from 7 high-volume hospitals in the Vanguard Multi-center Study of the International Living Donor Liver Transplantation Group and reviewed it retrospectively. Of the 43 cases, there were 24 recipient-related abortion cases and 19 donor-related cases. Recipient-related abortions included pulmonary hypertension (n = 8), hemodynamic instability (n = 6), advanced hepatocellular carcinoma (n = 5), bowel necrosis (n = 4), and severe adhesion (n = 1). Donor-related abortions included graft steatosis (n = 7), graft fibrosis (n = 5), primary biliary cholangitis (n = 3), anaphylactic shock (n = 2), and hemodynamic instability (n = 2). Total incidence of aborted LDLT was 0.31%, and there was no remarkable difference between the centers. A strategy to minimize additional donor damage by delaying the donor's laparotomy or trying to open the recipient's abdomen with a small incision should be effective in preventing some causes of aborted LDLT, such as pulmonary hypertension, advanced cancer, and severe adhesions.

Robotic and laparoscopic right lobe living donation compared to the open approach: A multicenter study on 1194 donor hepatectomies.

Due to the success of minimally invasive liver surgery, laparoscopic and robotic minimally invasive donor hepatectomies (MIDH) are increasingly performed worldwide. We conducted a retrospective, multicentre, propensity score-matched analysis on right lobe MIDH by comparing the robotic, laparoscopic, and open approaches to assess the feasibility, safety, and early outcomes of MIDHs. From January 2016 until December 2020, 1194 donors underwent a right donor hepatectomy performed with a robotic (n = 92), laparoscopic (n = 306), and open approach (n = 796) at 6 high-volume centers. Donor and recipients were matched for different variables using propensity score matching (1:1:2). Donor outcomes were recorded, and postoperative pain was measured through a visual analog scale. Recipients' outcomes were also analyzed. Ninety-two donors undergoing robotic surgery were matched and compared to 92 and 184 donors undergoing laparoscopic and open surgery, respectively. Conversions to open surgery occurred during 1 (1.1%) robotic and 2 (2.2%) laparoscopic procedures. Robotic procedures had a longer operative time (493 ± 96 min) compared to laparoscopic and open procedures (347 ± 120 and 358 ± 95 min; p < 0.001) but were associated with reduced donor blood losses ( p < 0.001). No differences were observed in overall and major complications (≥ IIIa). Robotic hepatectomy donors had significantly less pain compared to the 2 other groups ( p < 0.001). Fifty recipients of robotic-procured grafts were matched to 50 and 100 recipients of laparoscopic and open surgery procured grafts, respectively. No differences were observed in terms of postoperative complications, and recipients' survival was similar ( p =0.455). In very few high-volume centers, robotic right lobe procurement has shown to be a safe procedure. Despite an increased operative and the first warm ischemia times, this approach is associated with reduced intraoperative blood losses and pain compared to the laparoscopic and open approaches. Further data are needed to confirm it as a valuable option for the laparoscopic approach in MIDH.

Prognostic significance of MRI features in patients with solitary large hepatocellular carcinoma following surgical resection.

OBJECTIVE: To assess the prognostic impact of preoperative MRI features on outcomes for single large hepatocellular carcinoma (HCC) (≥ 8 cm) after surgical resection. MATERIAL AND METHODS: This retrospective study included 151 patients (mean age: 59.2 years; 126 men) with a single large HCC who underwent gadoxetic acid-enhanced MRI and surgical resection between 2008 and 2020. Clinical variables, including tumor markers and MRI features (tumor size, tumor margin, and the proportion of hypovascular component on hepatic arterial phase (AP) (≥ 50% vs. < 50% tumor volume) were evaluated. Cox proportional hazards model analyzed overall survival (OS), recurrence-free survival (RFS), and associated factors. RESULTS: Among 151 HCCs, 37.8% and 62.2% HCCs were classified as ≥ 50% and < 50% AP hypovascular groups, respectively. The 5- and 10-year OS and RFS rates in all patients were 62.0%, 52.6% and 41.4%, 38.5%, respectively. Multivariable analysis revealed that ≥ 50% AP hypovascular group (hazard ratio [HR] 1.7, p = 0.048), tumor size (HR 1.1, p = 0.006), and alpha-fetoprotein ≥ 400 ng/mL (HR 2.6, p = 0.001) correlated with poorer OS. ≥ 50% AP hypovascular group (HR 1.9, p = 0.003), tumor size (HR 1.1, p = 0.023), and non-smooth tumor margin (HR 2.1, p = 0.009) were linked to poorer RFS. One-year RFS rates were lower in the ≥ 50% AP hypovascular group than in the < 50% AP hypovascular group (47.4% vs 66.9%, p = 0.019). CONCLUSION: MRI with ≥ 50% AP hypovascular component and larger tumor size were significant factors associated with poorer OS and RFS after resection of single large HCC (≥ 8 cm). These patients require careful multidisciplinary management to determine optimal treatment strategies. CLINICAL RELEVANCE STATEMENT: Preoperative MRI showing a ≥ 50% arterial phase hypovascular component and larger tumor size can predict worse outcomes after resection of single large hepatocellular carcinomas (≥ 8 cm), underscoring the need for tailored, multidisciplinary treatment strategies. KEY POINTS: MRI features offer insights into the postoperative prognosis for large hepatocellular carcinoma. Hypovascular component on arterial phase ≥ 50% and tumor size predicted poorer overall survival and recurrence-free survival. These findings can assist in prioritizing aggressive and multidisciplinary approaches for patients at risk for poor outcomes.

Comparison between laparoscopic liver resection and open liver resection in patients with hepatocellular carcinoma with portal vein tumor thrombosis.

BACKGROUND: Recently, the outcomes of surgical treatment for advanced hepatocellular carcinoma (HCC) have improved. However, despite the technical advancements in laparoscopic liver resection (LLR), it is still not recommended as the standard treatment for HCC with portal vein tumor thrombosis (PVTT) because of the poor oncological outcomes. This study aims to compare the clinical outcomes of open liver resection (OLR) and LLR in patients with HCC with PVTT. METHODS: A total of 86 patients with PVTT confirmed in the pathological report between January 2014 and December 2018, were enrolled. Short-term, postoperative, and long-term outcomes, including recurrence-free survival and overall survival rates, were evaluated. RESULTS: No difference between the two groups, except for age, was detected. The median age in the laparoscopic group was significantly higher than that in the open group. Regarding the pathological features, the maximal tumor size was significantly larger in the OLR; other pathological factors did not differ. There was no significant difference between overall survival (OS) and recurrence-free survival (RFS). Vp3 PVTT (hazards ratio [HR] 6.1, 95% confidence interval [CI] 1.9-18.5), Edmondson grade IV (HR 4.7, 95% CI 1.7-12.9, p = 0.003), and intrahepatic metastasis (HR 3.9, 95% CI 2.1-7.2, p < 0.001) remained the unique independent predictors of recurrence-free survival according to a multivariate Cox proportional hazard regression analysis. CONCLUSIONS: Laparoscopic liver resection for the management of HCC with PVTT provides the same short- and long-term results as those of the open approach.

Risk Factors Associated With Surgical Morbidities of Laparoscopic Living Liver Donors.

OBJECTIVE: This study analyzed the incidence and risk factors for surgical morbidities of laparoscopic living donors. BACKGROUND: Although laparoscopic living donor programs have been established safely in leading centers, donor morbidities have not been discussed sufficiently. METHODS: Laparoscopic living donors operated on from May 2013 to June 2022 were reviewed. Donor complications were reviewed, and factors related to bile leakage and biliary stricture were analyzed using the multivariable logistic regression method. RESULTS: A total of 636 donors underwent laparoscopic living donor hepatectomy. The open conversion rate was 1.6%, and the 30-day complication rate was 16.8% (n=107). Grade IIIa and IIIb complications occurred in 4.4% (n=28) and 1.9% (n=12) of patients, respectively. The most common complication was bleeding (n=38, 6.0%). Fourteen donors (2.2%) required reoperation. Portal vein stricture, bile leakage, and biliary stricture occurred in 0.6% (n=4), 3.3% (n=21), and 1.6% (n=10) of cases, respectively. The readmission rate and reoperation rate were 5.2% (n=33) and 2.2% (n=14), respectively. Risk factors related to bile leakage were 2 hepatic arteries in the liver graft (OR=13.836, CI=4.092-46.789, P <0.001), division-free margin<5 mm from the main duct (OR=2.624, CI=1.030-6.686, P =0.043), and estimated blood loss during operation (OR=1.002, CI=1.001-1.003, P =0.008), while the Pringle maneuver (OR=0.300, CI=0.110-0.817, P =0.018) was protective against leakage. Regarding biliary stricture, bile leakage was the only significant factor (OR=11.902, CI=2.773-51.083, P =0.001). CONCLUSIONS: Laparoscopic living donor surgery showed excellent safety for the majority of donors, and critical complications were resolved with proper management. To minimize bile leakage, cautious surgical manipulation is needed for donors with complex hilar anatomy.

Pretransplant mycophenolate mofetil may be associated with reduced intrahepatic cholangiopathy in ABO-incompatible liver transplantation.

Intrahepatic cholangiopathy is a life-threatening sequela of ABO-incompatible liver transplantation. We analyzed the clinical impact of pretransplant administration of mycophenolate mofetil in reducing intrahepatic cholangiopathy in ABO-incompatible liver transplantation. Patients who underwent living donor liver transplantation between 2010 and April 2022 were included. Pretransplant mycophenolate mofetil was started in November 2020. A comparison between patients who experienced intrahepatic cholangiopathy and who did not among ABO-incompatible transplantation was performed. Recipients of ABO-incompatible transplantations were categorized based on donor surgery into open, laparoscopy without pretransplant mycophenolate mofetil, and laparoscopy with pretransplant mycophenolate mofetil groups. Cox analysis of intrahepatic cholangiopathy was performed. A total of 234 ABO-incompatible transplantations were included. Intrahepatic cholangiopathy occurred in 1.1% (n=1/94), 13.3% (n=12/90), and 2.0% (n=1/50) of patients who received an ABO-incompatible liver with open surgery, laparoscopic donor surgery without pretransplant mycophenolate mofetil and laparoscopic donor surgery with pretransplant mycophenolate mofetil. ( p = 0.001) Multivariable analysis showed that transplantations involving a donor who underwent a laparoscopic hepatectomy and a recipient who did not receive pretransplant mycophenolate mofetil were associated with a higher risk of intrahepatic cholangiopathy (HR=13.449, CI=1.710-105.800, p = 0.02) compared with transplantations from donors who underwent open surgery. Transplantations involving a donor who underwent laparoscopic donor surgery and a recipient who received pretransplant mycophenolate mofetil resulted in no increased risk compared with transplantations from donors who underwent open surgery. (HR=5.307, CI=0.315-89.366, p = 0.25) Laparoscopic donor hepatectomy was a risk factor for intrahepatic cholangiopathy in ABO-incompatible liver transplantation, while pretransplant mycophenolate mofetil was related to risk reduction of intrahepatic cholangiopathy.

Comparison of pure laparoscopic donor right posterior sectionectomy versus right hemihepatectomy for living donor liver transplantation.

The right posterior section (RPS) graft for living donor liver transplantation is an alternative graft in a live liver donor with insufficient remnant left lobe volume and portal vein anomaly. Although there have been some reports regarding pure laparoscopic donor right posterior sectionectomy (PLDRPS), no study has compared PLDRPS versus pure laparoscopic donor right hemihepatectomy (PLDRH). The aim of our study was to compare the surgical outcomes of PLDRPS versus PLDRH at centers achieving a complete transition from open to laparoscopic approach in liver donor surgery. From March 2019 to March 2022, a total of 351 living donor liver transplantations, including 16 and 335 donors who underwent PLDRPS and PLDRH, respectively, were included in the study. In the donor cohort, there were no significant differences in major complication (≥grade III) rate and comprehensive complication index between the PLDRPS versus PLDRH group (6.3% vs. 4.8%; p = 0.556 and 2.7 ± 8.6 vs.1.7 ± 6.4; p = 0.553). In the recipient cohort, there was a significant difference in major complication (≥grade III) rate (62.5% vs. 35.2%; p = 0.034) but no significant difference in comprehensive complication index (18.3 ± 14.9 vs. 15.2 ± 24.9; p = 0.623) between the PLDRPS and PLDRH groups. PLDRPS in live liver donors with portal vein anomaly and insufficient left lobe was technically feasible and safe with experienced surgeons. The PLDRPS group might be comparable with the PLDRH group based on the surgical outcomes of donors and recipients. However, in terms of recipient outcomes, more careful selection of donors of the RPS graft and further research in a large number of cases are necessary to evaluate the usefulness of PLDRPS.

Improved recurrence-free survival in patients with HCC with post-transplant plasma exchange.

Total plasma exchange (TPE) can play a role in cancer treatment by eliminating immune checkpoint inhibitors. This study investigated whether TPE improved oncological outcomes in patients with HCC who underwent ABO-incompatible living donor liver transplantation (LT). The study included 152 patients who underwent ABO-incompatible living donor LT for HCC between 2010 and 2021 at Samsung Medical Center. Overall survival was analyzed using the Kaplan-Meier curve, whereas HCC-specific recurrence-free survival (RFS) was analyzed using the cumulative incidence curve after propensity score matching. Cox regression and competing risks subdistribution hazard models were used to identify the risk factors associated with overall survival and HCC-specific RFS, respectively. The propensity score matching resulted in 54 matched pairs, grouped according to whether they underwent postoperative TPE [post-transplant TPE(+)] or not [post-transplant TPE(-)]. The 5-year HCC-specific RFS cumulative incidence was superior in the post-transplant TPE (+) group [12.5% (95% CI: 3.1%-21.9%)] compared with the post-transplant TPE(-) group [38.1% (95% CI: 24.4%-51.8%), p = 0.005]. In subgroup analysis for patients with microvascular invasion and those beyond the Milan criteria, the post-transplant TPE(+) group showed significantly superior HCC-specific survival. The multivariable analysis also showed that postoperative TPE had a protective effect on HCC-specific RFS (HR = 0.26, 95% CI: 0.10-0.64, p = 0.004) and that the more post-transplant TPE was performed, the better RFS was observed (HR = 0.71, 95% CI: 0.55-0.93, p = 0.012). Post-transplant TPE was found to improve RFS after ABO-incompatible living donor LT for HCC, particularly in advanced cases with microvascular invasion and beyond Milan criteria. These findings suggest that TPE may have a potential role in improving oncological outcomes in patients with HCC undergoing LT.

Entecavir versus tenofovir on the recurrence of hepatitis B-related HCC after liver transplantation: A multicenter observational study.

Considerable controversy exists regarding the superiority of tenofovir disoproxil fumarate (TDF) over entecavir (ETV) for reducing the risk of HCC. This study aimed to compare outcomes of ETV versus TDF after liver transplantation (LT) in patients with HBV-related HCC. We performed a multicenter observational study using data from the Korean Organ Transplantation Registry. A total of 845 patients who underwent LT for HBV-related HCC were divided into 2 groups according to oral nucleos(t)ide analogue used for HBV prophylaxis post-LT: ETV group (n = 393) and TDF group (n = 452). HCC recurrence and overall death were compared in naïve and propensity score (PS)-weighted populations, and the likelihood of these outcomes according to the use of ETV or TDF were analyzed with various Cox models. At 1, 3, and 5 years, the ETV and TDF groups had similar HCC recurrence-free survival (90.7%, 85.6%, and 84.1% vs. 90.9%, 84.6%, and 84.2%, respectively, p = 0.98) and overall survival (98.4%, 94.7%, and 93.5% vs. 99.3%, 95.8%, and 94.9%, respectively, p = 0.48). The propensity score-weighted population showed similar results. In Cox models involving covariates adjustment, propensity score-weighting, competing risk regression, and time-dependent covariates adjustment, both groups showed a similar risk of HCC recurrence and overall death. In subgroup analyses stratified according to HCC burden (Milan criteria, Up-to-7 criteria, French alpha-fetoprotein risk score), pretransplantation locoregional therapy, and salvage LT, neither ETV nor TDF was superior. In conclusion, ETV and TDF showed mutual noninferiority for HCC outcomes when used for HBV prophylaxis after LT.

Near-zero open conversion rate of laparoscopic liver resection: a high-volume single-center experience of the past 5 years.

BACKGROUND: Despite widespread adoption and technological advances in laparoscopic liver resection (LLR), conversion to laparotomy can still occur unexpectedly. Several studies have explored risk factors of open conversion (OC). However, most of these studies were conducted before 2018 and included all patients who underwent surgery at an early stage after starting LLR. The purpose of this study was to analyze the incidence and risk factors of OC in patients within the past 5 years (2017-2021). METHODS: Patients who underwent LLR at Samsung Medical Center from January 2017 to December 2021 were investigated. The incidence and causes of OC were investigated and risk factors associated with OC were also analyzed. RESULTS: A total of, 1951 patients were investigated. OC was observed in 34 patients (1.74%). The percentage of previous surgeries (50% vs. 25.5%, P < 0.001), history of hepatectomy (23.5% vs. 5.4%, P = 0.002), multi-focal disease (29.4% vs. 13.9%, P = 0.037), and posterosuperior (PS) location (64.7% vs. 39%, P = 0.004) were higher in the OC group. The most common cause of OC was adhesion (44.1%). In the analysis of risk factors associated with OC, PS location (OR 2.79, P = 0.007) and maximum tumor size (OR 0.92, P = 0.037) were statistically significant factors in multivariate analysis. CONCLUSION: The updated incidence of OC was 1.74%. The main cause of OC was adhesion. In addition, PS location and smaller tumor size were risk factors associated with OC.

Analysis of Antibody Responses After COVID-19 Vaccination in Liver Transplant Recipients: A Single-Center Study.

BACKGROUND: Liver transplant (LT) recipients were considered a vulnerable population during the coronavirus disease 2019 (COVID-19) pandemic. The clinical efficacy of the COVID-19 vaccine is unknown in immunocompromised patients. The purpose of this study was to provide evidence of antibody responses after COVID-19 vaccination in LT recipients. METHODS: This study enrolled 46 patients who underwent LT at Samsung Medical Center (Seoul, Korea) before implementation of the one-dose vaccine in Korea. Those who completed the two-dose COVID-19 vaccine between August 2021 and September 2021 were included and followed through December 2021. Semiquantitative anti-spike serologic testing was performed using the Roche Elecsys anti-SARS-CoV-2 S enzyme immunoassay (Roche Diagnostics, Rotkereuz, Switzerland) with a positive cutoff of at least 0.8 U/mL. RESULTS: Among all 46 participants, 40 (87%) demonstrated an antibody response after the second dose of a COVID-19 vaccine, while six (13%) had no antibody response after the second dose. Upon univariate analysis, patients with higher antibody titer had longer years since LT (2.3 ± 2.8 vs. 9.4 ± 5.0, P < 0.001). A lower median tacrolimus (TAC) level before vaccination and after the second dose of COVID-19 vaccine indicated a significantly higher antibody response (2.3 [1.6-3.2] vs. 7.0 [3.7-7.8], P = 0.006, 2.5 [1.6-3.3] vs. 5.7 [4.2-7.2], P = 0.003). Period between 2nd vaccination and serologic testing was significantly higher in the antibody-response group compared to the no-antibody-response group (30.2 ± 24.0 vs. 65.9 ± 35.0, P = 0.012). A multivariate analysis of antibody responses revealed TAC level before vaccination as a statistically significant factor. CONCLUSION: A higher TAC level before vaccination resulted in less effective vaccination in LT patients. Booster vaccinations are required, especially for patients in the early stage after LT who have compromised immune function.

Complete transition from open surgery to laparoscopy: 8-year experience with more than 500 laparoscopic living donor hepatectomies.

This study was designed to review laparoscopic living donor liver transplantations (LDLTs) at a single center that achieved complete transition from open surgery to laparoscopy. LDLTs performed from January 2013 to July 2021 were reviewed. Comparisons between open and laparoscopic surgeries were performed according to periods divided into initial, transition, and complete transition periods. A total of 775 LDLTs, 506 laparoscopic and 269 open cases, were performed. Complete transition was achieved in 2020. Bile duct variations were significantly abundant in the open group both in the initial period (30.2% vs. 8.1%; p < 0.001) and transition period (48.1% vs. 24.3%; p < 0.001). Portal vein variation was more abundant in the open group only in the initial period (13.0% vs. 4.1%; p = 0.03). Although the donor reoperation rate (0.0% vs. 4.1%; p = 0.02) and Grade III or higher complication rate (5.6% vs. 13.5%; p = 0.03) were significantly higher in the laparoscopy group in the initial period, there were no differences during the transition period as well as in overall cases. Median number of opioids required by the donor (three times [interquartile range, IQR, 1-6] vs. 1 time [IQR, 0-3]; p < 0.001) was lower, and the median hospital stay (10 days [IQR, 8-12] vs. 8 days [IQR, 7-9]; p < 0.001) was shorter in the laparoscopy group. Overall recipient bile leakage rate (23.8% vs. 12.8%; p < 0.001) and overall Grade III or higher complication rate (44.6% vs. 37.2%; p = 0.009) were significantly lower in the laparoscopy group. Complete transition to laparoscopic living donor hepatectomy was possible after accumulating a significant amount of experience. Because donor morbidity can be higher in the initial period, donor selection for favorable anatomy is required for both the donor and recipient.

Healthy Spouses can be Considered as Living Liver Donors.

BACKGROUND: Spousal donors have gradually been accepted as an alternative living liver donors to alleviate the organ shortage and prevent donations from children. No information is available regarding the effects of spousal donation on donor safety and recipient outcomes. Our purpose in this study was to determine how spousal liver grafts in living donor liver transplantation (LDLT) affect donor safety and recipient outcomes compared with those of LDLT from children. METHODS: We retrospectively analyzed 656 patients, including spouses and children, who underwent a right or extended right hepatectomy for living liver donation between January 2009 and December 2018. RESULTS: Spouses represented 18.8% (n = 123) of living liver donors. Female donors comprised 78.9% (n = 97) of spousal donors, and the proportion of male donors in the children group was 72.6% (n = 387). The mean donor operation time of the spousal group was shorter than that of the children group (330 min vs. 358 min; P = 0.011), and the complication rate in the spousal group was lower than that in the children group (12.2% vs. 22.9%; P = 0.006). However, there were no differences in severe complication rates, hospitalization, or liver function tests between the 2 groups at 3 months after donor surgery. The overall survival of recipients in the spousal group was not reduced compared to that of recipients in the children group. CONCLUSION: The present study suggests that, with careful selection, spousal donation is feasible and safe in LDLT.

Surgical Resection Is Preferred in Selected Solitary Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis.

INTRODUCTION: Sorafenib is the standard care for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT), though it offers limited survival. This study was designed to compare clinical outcomes between liver resection (surgery) and transarterial chemoembolization plus radiotherapy (TACE-RT) as the initial treatment modality for resectable treatment-naïve solitary HCC combined with subsegmental (Vp1), segmental (Vp2), and lobar (Vp3) PVTT. METHODS: From the institutional HCC registry, we identified 116 patients diagnosed with resectable treatment-naïve HCC with Vp1-Vp3 PVTT based on radiologic images who received surgery (n = 44) or TACE-RT (n = 72) as a primary treatment between 2010 and 2015. A propensity score matching (PSM) model was created. RESULTS: The TACE-RT group had a higher tumor burden (tumor size, extent, and markers) than the surgery group. Cumulative patient survival curve in the surgery group was significantly higher than that in the TACE-RT group before and after PSM. Liver function was relatively well preserved in the surgery group compared with the TACE-RT group. TACE-RT group, male, increased alkaline phosphatase, and increased platelet count were predisposing factors for patient death in resectable treatment-naïve solitary HCC with PVTT. DISCUSSION/CONCLUSION: The present study suggests that surgery is considered as an initial treatment in selectively resectable treatment-naïve solitary HCC with Vp1-Vp3 PVTT.

Laparoscopic Living Donor Right Hepatectomy Regarding the Anatomical Variation of the Portal Vein: A Propensity Score-Matched Analysis.

This study is designed to analyze the feasibility of laparoscopic living donor right hemihepatectomy in living donors with portal vein variation. Living donor liver transplantation cases using a right liver graft during the period of January 2014 to September 2019 were included. Computed tomographic angiographies of the donor were 3-dimensionally reconstructed, and the anatomical variation of the portal vein was classified. To reduce selection bias, a 1:1 ratio propensity score-matched analysis between the laparoscopy group and the open group was performed. Surgical and recovery-related outcomes as well as portal vein complication-free survival, graft survival, and overall survival rates were analyzed. After matching, 171 cases in each group from 444 original cases were compared. The laparoscopy group had a shorter operation time (P < 0.001), a smaller number of additional opioids required by the donor (P < 0.001), and a shorter hospital stay (P < 0.001). There were no differences in the portal vein complication-free survival (P = 0.16), graft survival (P = 0.26), or overall survival rates (P = 0.53). Although portal vein complication-free survival was inferior in portal veins other than type I (P = 0.01), the laparoscopy group showed similar portal vein complication-free survival regardless of the anatomical variation of portal vein (P = 0.35 in type I and P = 0.30 in other types). Laparoscopic living donor right hemihepatectomy can be performed as safely as open surgery regardless of the anatomical variation of the portal vein.

Image guidance using two-dimensional illustrations and three-dimensional modeling of donor anatomy during living donor hepatectomy.

BACKGROUND: For living donor liver transplantation, preoperative imaging is required for the safety of both the donor and the recipient. We previously initiated our image-guidance program using two-dimensional illustrations and three-dimensional modeling in September 2018; herein, we analyzed the resultant changes in the clinical outcomes. METHODS: Living donors and recipients who underwent liver transplantation between September 2017 and August 2019 were included. Cases with image guidance were compared to those without image guidance regarding the operative outcome, especially bile-duct opening in the graft as well as surgical complications. RESULTS: Among 200 living donor transplantation, 90 transplantations were completed with image guidance. The image-guidance group had a higher rate of laparoscopy (80.9% vs. 97.8%; p < .001) as compared with the group without image guidance. Although there was no difference in the type of bile duct (p = .144), more grafts with single bile-duct openings were found in the image-guidance group (52.7% vs. 80.0%; p = .001). Consequently, achievements in bile-duct openings were superior in the image-guidance group (p = .022). There were no differences in bile leakage, graft failure, or number of deaths during the first month post-transplantation. CONCLUSION: As we initiated our image-guidance program for living donor liver transplantation, clinical outcomes, especially bile-duct division, were improved relative to before implementation.

Venous outflow congestion is related to poor recurrence-free survival of living donor liver transplantation recipients with hepatocellular carcinoma - a retrospective study.

This study analyzed the impact of venous outflow congestion in the liver graft on hepatocellular carcinoma recurrence in liver transplantation recipients. Hepatocellular carcinoma patients who underwent living donor liver transplantation at Samsung Medical Center between 2007 and 2018 were included. The congested volume was calculated based on 2-week post-transplantation computed tomography. Recurrence-free survival and overall survival were analyzed using the multivariable Cox proportional hazard model including the degree of venous congestion. A total of 582 patients were included. There were 232 patients (39.9%) with certain degree of congestion volume. Kaplan-Meier survival analyses showed 1-, 5-, and 10-year recurrence-free survivals of 86.0%, 72.2%, and 70.7%, respectively, and overall survivals of 91.5%, 73.4%, and 68.9%, respectively. While congestion volume per 10 cm3 was a significant risk factor for recurrence-free survival (HR = 1.024, CI: 1.002-1.047, P = 0.034), there was no significant relationship with overall survival. (HR = 1.015, CI: 0.992-1.039, P = 0.213). Venous outflow congestion in the liver after living donor liver transplantation was related to the poor recurrence-free survival of hepatocellular carcinoma patients.

Coagulation biomarkers in healthy male Cynomolgus macaque monkeys (Macaca fascicularis).

We designed this study to define reference values of the cynomolgus monkey coagulation system, as the normal range of values has not been established. Measurement of coagulation function was determined by testing plasma samples from 30 healthy male cynomolgus monkeys. Prothrombin time (PT), PT activity, PT international normalized ratio (INR), activated prothrombin time (aPTT), antithrombin III activity, factor II, V, VII, VIII, IX, X, XI, and XII, protein C activity, protein S activity, and d-dimer were measured using standardized techniques. Mean age and body weight were 69.5 ± 11.8 months and 5.3 ± 0.8 kg, respectively. The mean PT, PT activity, PT INR, aPTT, and antithrombin III activities were 11.72 seconds (95% CI = 10.55-12.88), 143.4% (95% CI = 102.0-184.9), 0.85 (95% CI = 0.74-0.96), 28.2 seconds (95% CI = 23.24-33.09), and 99.7% (95% CI = 79.2-120.3), respectively. The mean activities of factors II, V, VII, VIII, IX, X, XI, and XII were 110.2% (95% CI = 88.8-131.5), 134.1% (95% CI = 73.0-195.2), 318.9% (95% CI = 185.0-452.9) 160.2% (95% CI = 96.9-261.3), 38.0% (95% CI = 20.9-55.1), 85.7% (95% CI = 61.4-110.0), 155.0% (95% CI = 81.4-228.6), and 353.7% (95% CI = 246.7-460.6), respectively. The mean activities of protein C and protein S were 195.7% (95% CI = 133.4-258.0) and 122.7% (95% CI = 83.2-162.3), respectively. The mean level of d-dimer was 1.80 µg/mL (95% CI = 0.27-3.33). Factors V (P = 0.008), IX (P = 0.002), and XI (P = 0.002), and protein S activity (P = 0.025) were positively correlated with age. Our study presented the baseline values of coagulation biomarkers of cynomolgus monkeys. Despite the similarity to previous published studies, more data are required to elucidate the age effect on coagulation biomarkers.

Optimal maximum duration for delaying salvage operation when recurrence of retroperitoneal liposarcoma is suspected: a single-center study.

BACKGROUND: This study was designed to identify the optimal maximum duration for delaying salvage operation when recurrence of retroperitoneal liposarcoma (LPS) is suspected. METHODS: Patients who underwent salvage operation at Samsung Medical Center for recurrent retroperitoneal LPS from January 2000 to December 2015 were reviewed. The time interval between recurrence and operation for recurrence was divided by 1, 2 or 3 months. A Cox proportional-hazards model was used to analyze factors related to disease-free survival along with recurrence-to-operation interval divided by 1, 2 or 3 months. RESULTS: The 1-, 3-, and 5-year disease-free survival rates were 43.2%, 15.6% and 13.4%, respectively. FNCLCC grade (p = 0.023) and recurrence-to-operation interval divided by 3 months (p = 0.003) were significant factors associated with recurrence. FNCLCC grade 2 (HR 1.940, CI 0.935-4.026, p = 0.238) and grade 3 (HR 4.049, CI 1.767-9.281, p = 0.007) showed increased risk compared to grade 1. Patients who underwent salvage operation more than 3 months after recurrence showed significantly increased risk of recurrence compared to patients within 3 months (HR 2.724, CI 1.391-5.337, p = 0.003). CONCLUSIONS: Based on our analysis of recurrence-free survival, salvage operation can be delayed for less than 3 months when recurrence is suspected. A short-term follow-up imaging study should be performed within this period.