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Shehta A, Elshobari M, Salah T, Sultan AM, Yasen A, Shiha U, El-Saadany M, Monier A, Said R, Habl MS, Adly R, El Ged BAE, Karam R, Khaled R, El Razek HMA, Abdel-Khalek EE, Wahab MA. Feasibility and outcomes of living-donor liver transplantation utilizing the right hemi-liver graft with portal vein anatomical variations. Langenbecks Arch Surg 2023; 408:387. [PMID: 37792043 PMCID: PMC10550851 DOI: 10.1007/s00423-023-03115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Portal vein (PV) reconstruction is a key factor for successful living-donor liver transplantation (LDLT). Anatomical variations of right PV (RPV) are encountered among potential donors. METHODS To evaluate a single center experience of reconstruction techniques for the right hemi-liver grafts with PV variations during the period between May 2004 and 2022. RESULTS A total of 915 recipients underwent LDLT, among them 52 (5.8%) had RPV anatomical variations. Type II PV was found in 7 cases (13.5%), which were reconstructed by direct venoplasty. Type III PV was found in 27 cases (51.9%). They were reconstructed by direct venoplasty in 2 cases (3.8%), Y graft interposition in 2 cases (3.8%), and in situ double PV anastomoses in 23 cases (44.2%). Type IV PV was found in 18 cases (34.6%) and was reconstructed by Y graft interposition in 9 cases (17.3%), and in situ double PV anastomoses in 9 cases (17.3%). Early right posterior PV stenosis occurred in 2 recipients (3.8%). Early PV thrombosis occurred in 3 recipients (5.8%). The median follow-up duration was 54.5 months (4 - 185). The 1-, 3-, and 5-years survival rates were 91.9%, 86%, and 81.2%, respectively. Late PV stenosis occurred in 2 recipients (3.8%) and was managed conservatively. CONCLUSION Utilization of potential living donors with RPV anatomic variations may help to expand the donor pool. We found that direct venoplasty and in situ dual PV anastomoses techniques were safe, feasible, and associated with successful outcomes.
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Affiliation(s)
- Ahmed Shehta
- Gastrointestinal Surgery Center, Department of Surgery, Faculty of Medicine, Mansoura University, Gehan Street, Mansoura, Postal code: 35516, Egypt.
| | - Mohamed Elshobari
- Gastrointestinal Surgery Center, Department of Surgery, Faculty of Medicine, Mansoura University, Gehan Street, Mansoura, Postal code: 35516, Egypt
| | - Tarek Salah
- Gastrointestinal Surgery Center, Department of Surgery, Faculty of Medicine, Mansoura University, Gehan Street, Mansoura, Postal code: 35516, Egypt
| | - Ahmad M Sultan
- Gastrointestinal Surgery Center, Department of Surgery, Faculty of Medicine, Mansoura University, Gehan Street, Mansoura, Postal code: 35516, Egypt
| | - Amr Yasen
- Liver Transplantation Unit, Gastrointestinal Surgery Center, Department of Anesthesia, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Usama Shiha
- Liver Transplantation Unit, Gastrointestinal Surgery Center, Department of Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed El-Saadany
- Liver Transplantation Unit, Gastrointestinal Surgery Center, Department of Hepatology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ahmed Monier
- Gastrointestinal Surgery Center, Department of Surgery, Faculty of Medicine, Mansoura University, Gehan Street, Mansoura, Postal code: 35516, Egypt
| | - Rami Said
- Gastrointestinal Surgery Center, Department of Surgery, Faculty of Medicine, Mansoura University, Gehan Street, Mansoura, Postal code: 35516, Egypt
| | - Mohamed S Habl
- Liver Transplantation Unit, Gastrointestinal Surgery Center, Department of Hepatology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Reham Adly
- Liver Transplantation Unit, Gastrointestinal Surgery Center, Department of Hepatology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Basma Abd Elmoaem El Ged
- Liver Transplantation Unit, Gastrointestinal Surgery Center, Department of Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Rasha Karam
- Liver Transplantation Unit, Gastrointestinal Surgery Center, Department of Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Reem Khaled
- Liver Transplantation Unit, Gastrointestinal Surgery Center, Department of Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Hassan Magdy Abd El Razek
- Liver Transplantation Unit, Gastrointestinal Surgery Center, Department of Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ehab E Abdel-Khalek
- Liver Transplantation Unit, Gastrointestinal Surgery Center, Department of Hepatology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Abdel Wahab
- Gastrointestinal Surgery Center, Department of Surgery, Faculty of Medicine, Mansoura University, Gehan Street, Mansoura, Postal code: 35516, Egypt
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Li H, Wei L, Zhu M, Zeng Z, Qu W, Zhu Z. A novel approach of intraoperative cholangiography in laparoscopic left lateral sectionectomy in living donor liver transplantation. Surg Endosc 2023:10.1007/s00464-023-10066-1. [PMID: 37081244 DOI: 10.1007/s00464-023-10066-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 04/01/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Accurate division of bile duct during laparoscopic donor hepatectomy in living donor liver transplantation is essential. We here present a novel approach to achieve cholangiography via the bile duct stump of segment IV (B4 stump) during laparoscopic donor hepatectomy in adult-to-pediatric living donor liver transplantation. PATIENTS AND METHODS Donors who underwent laparoscopic left lateral sectionectomy (LLLS) from January 2022 to April 2022 in our liver transplant center were retrospectively analyzed. A total of 32 donors were eventually enrolled into this study. Cholangiography via the B4 stump was performed in 11 donors (B4 group) while indocyanine green (ICG) fluorescence guiding was performed in 21 donors (ICG group). Perioperative data were collected and compared between groups. RESULTS Cholangiography by catheterizing the B4 stump was successfully performed in all 11 donors in the B4 group. The mean time of this procedure was 12.82 ± 9.11 min. Compared to the ICG group, it was more likely to acquire single bile duct orifice on graft in the B4 group (B4: 10/11, 90.91% vs ICG: 9/21, 42.86%) and it was significantly different (p = 0.030). The donors' complications (Clavien-Dindo grade III-IV) were not significantly different. There was one donor developed intraperitoneal effusion in B4 group, while two donors (one bile leakage and one biliary stricture) developed biliary tract related complications in the ICG group. A Roux-en-Y was performed to solve the biliary stricture in the ICG group. The recipients' outcomes were not significantly different between groups. CONCLUSIONS Cholangiography via the B4 stump catheterization is feasible and safe in identifying the bifurcation of bile duct during LLLS.
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Affiliation(s)
- Hongyu Li
- Department of Liver Transplantation, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Lin Wei
- Department of Liver Transplantation, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Mingyue Zhu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhigui Zeng
- Department of Liver Transplantation, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Wei Qu
- Department of Liver Transplantation, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhijun Zhu
- Department of Liver Transplantation, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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3
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Hirukawa K, Masuda Y, Abe Y, Yagi H, Ibuki S, Itano O, Shinoda M, Kitago M, Hasegawa Y, Hori S, Tanaka M, Nakano Y, Matsubara K, Obara H, Yamada Y, Kuroda T, Hibi T, Kitagawa Y. Standardized upfront Glissonean approach and liver hanging maneuver reduces bile leakage from the hepatic hilum in living donors. Liver Transpl 2023; 29:48-57. [PMID: 35848084 DOI: 10.1002/lt.26545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/24/2022] [Accepted: 07/01/2022] [Indexed: 01/14/2023]
Abstract
Biliary complications after hepatectomy in living donors have yet to be eradicated. We hypothesized that a standardized upfront Glissonean approach and liver hanging maneuver (GH) would prevent mechanical and thermal injuries to the hilar plate of the remnant liver by determining the point of bile duct division and the final destination of hepatectomy preceding liver parenchymal transection (safety) and facilitate liver transection deep within the parenchyma and allow maximum length of hilar structures (rationality). GH was implemented in 2016 and its incidence of bile leakage was retrospectively compared against the conventional technique. GH comprises six steps: (1) development of the retrohepatic avascular plane between the right hepatic vein (RHV) and the middle hepatic vein (MHV) and isolation of the hepatic vein(s); (2) isolation of the right or left Glissonean pedicle with the corresponding Glissonean pedicles of the caudate lobe; (3) for right liver grafts and left liver grafts with the caudate lobe, passage of the tape for the liver hanging maneuver along the retrohepatic avascular plane and above the hilar plate, and for left liver grafts without the caudate lobe and for left lateral section grafts, passage of the tape from between the RHV and the MHV, along the Arantius ligament, and to the right of the umbilical portion; (4) liver transection; (5) isolation of hilar structures; and (6) graft procurement. Until 2020, 62 consecutive living donors underwent GH (success rate, 100%). The incidence of bile leakage from the hepatic hilum (0%) was significantly lower than that among 59 donors who underwent the conventional technique in 2011-2015 (9%; p = 0.01). In conclusion, GH is highly effective in reducing bile leakage from the hepatic hilum in living donors.
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Affiliation(s)
- Kazuya Hirukawa
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan.,Department of Pediatric Surgery and Transplantation , Kumamoto University Graduate School of Medical Sciences , Kumamoto , Japan
| | - Yuki Masuda
- Department of Gastroenterological Surgery , Tachikawa Hospital , Tokyo , Japan
| | - Yuta Abe
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Hiroshi Yagi
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Sho Ibuki
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan.,Department of Surgery , Shonantobu General Hospital , Kanagawa , Japan
| | - Osamu Itano
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan.,Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery , International University of Health and Welfare School of Medicine , Chiba , Japan
| | - Masahiro Shinoda
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan.,Digestive Diseases Center , International University of Health and Welfare , Mita Hospital , Tokyo , Japan
| | - Minoru Kitago
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Yasushi Hasegawa
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Shutaro Hori
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Masayuki Tanaka
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Yutaka Nakano
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Kentaro Matsubara
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Hideaki Obara
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Yohei Yamada
- Department of Pediatric Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Taizo Hibi
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan.,Department of Pediatric Surgery and Transplantation , Kumamoto University Graduate School of Medical Sciences , Kumamoto , Japan
| | - Yuko Kitagawa
- Department of Surgery , Keio University School of Medicine , Tokyo , Japan
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4
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Tuysuz U, Aktas H, Batı IB, Emıroglu R. The role of Intraoperative cholangiography (IOC) and methylene blue tests in reducing bile leakage after living donor hepatectomy. Asian J Surg 2020; 44:147-152. [PMID: 32807583 DOI: 10.1016/j.asjsur.2020.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/18/2020] [Accepted: 04/20/2020] [Indexed: 12/20/2022] Open
Abstract
AIM Liver transplantation remains the only curative treatment in end stage liver disease. Biliary complications remain the most common major morbidity causes in hepatic resection. We aimed to determine and eliminate the bile leakage in donor hepatectomy of LDLT. MATERIAL AND METHODS This study was conducted retrospective and one center study. The study population included 110 consequential liver donors with major liver resection (more than three segments). The population was divided into three groups for data analyses. Primary study groups included 40 donors subjected to methylene blue test starting in April 2013 and 40 donors subjected to intraoperative cholangiography started in March 2014. RESULTS A total of 110 liver donors (42.7% women) were included in the study. Postoperative biliary complications were less in methylene blue and intraoperative cholangiography (IOC) groups. Bile leakage was significantly higher in control group (23.3%) compared to methylene blue (5%) and IOC groups (2%) Average duration of hospital stay and duration of operation were significantly higher in control group compared to methylene blue and IOC groups. CONCLUSION In our study we conducted to establish biliary leakage in living donor hepatectomy which intraoperative cholangiography test was used to determine. Many intraoperative methods have been introduced to prevent biliary leakage and development of complications. We have showed that IOC test used in the present study could be easily applied in both living liver donor hepatectomy and other major hepatectomy cases. IOC test reduced postoperative biliary leakage incidence and did not increase incidence of other complications.
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Affiliation(s)
- Umut Tuysuz
- Departman of Hepatopancreatobiliary Surgery, Şişli Etfal Hamidiye Training and Research Hospital, İstanbul, Turkey.
| | - Hıkmet Aktas
- Departman of Transplant Surgery, Faculty of Medicine, Acıbadem Unıversity, İstanbul, Turkey
| | - Imam Bakır Batı
- Departman of Transplant Surgery, Faculty of Medicine, Acıbadem Unıversity, İstanbul, Turkey
| | - Remzi Emıroglu
- Departman of Transplant Surgery, Faculty of Medicine, Acıbadem Unıversity, İstanbul, Turkey
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5
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Clamp-Crush Technique Versus Harmonic Scalpel for Hepatic Parenchymal Transection in Living Donor Hepatectomy: a Randomized Controlled Trial. J Gastrointest Surg 2019; 23:1568-1577. [PMID: 30671805 DOI: 10.1007/s11605-019-04103-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 01/01/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hepatic parenchymal transection is the most invasive step in donor operation. During this step, blood loss and unintended injuries to the intrahepatic structures and hepatic remnant may occur. There is no evidence to prove the ideal techniques for hepatic parenchymal transection. The aim of this study is to compare the safety, efficacy, and outcome of clamp-crush technique versus harmonic scalpel as a method of parenchymal transection in living-donor hepatectomy. METHODS Consecutive living liver donors, undergoing right hemi-hepatectomy, during the period between May 2015 and April 2016, were included in this prospective randomized study. Cases were randomized into two groups; group (A) harmonic scalpel group and group (B) Clamp-crush group. RESULTS During the study period, 72 cases underwent right hemi-hepatectomy for adult living donor liver transplantation and were randomized into two groups. There were no statistically significant differences between the two groups regarding preoperative demographic and radiological data. Longer operation time and hepatectomy duration were found in group B. There were no significant differences between the two groups regarding blood loss, blood loss during hepatectomy, and blood transfusion. More unexpected bleeding events occurred in group A. Higher necrosis at the cut margin of the liver parenchyma was noted in group A. There were no statistically significant differences between the two groups regarding postoperative ICU stay, hospital stay, postoperative morbidities, and readmission rates. CONCLUSION Clamp-crush technique is advocated as a simple, easy, safe, and cheaper method for hepatic parenchymal transection in living donors.
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6
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Luciano MP, Namgoong JM, Nani RR, Nam SH, Lee C, Shin IH, Schnermann MJ, Cha J. A Biliary Tract-Specific Near-Infrared Fluorescent Dye for Image-Guided Hepatobiliary Surgery. Mol Pharm 2019; 16:3253-3260. [PMID: 31244218 DOI: 10.1021/acs.molpharmaceut.9b00453] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite advances, visual inspection, palpation, and intraoperative ultrasound remain the most utilized tools during surgery today. A particularly challenging issue is the identification of the biliary system due to its complex architecture partially embedded within the liver. Fluorescence guided surgical interventions, particularly using near-infrared (NIR) wavelengths, are an emerging approach for the real-time assessment of the hepatobiliary system. However, existing fluorophores, such as the FDA-approved indocyanine green (ICG), have significant limitations for rapid and selective visualization of bile duct anatomy. Here we report a novel NIR fluorophore, BL (Bile Label)-760, which is exclusively metabolized by the liver providing high signal in the biliary system shortly after intravenous administration. This molecule was identified by first screening a small set of known heptamethine cyanines including clinically utilized agents. After finding that none of these were well-suited, we then designed and tested a small series of novel dyes within a prescribed polarity range. We validated the molecule that emerged from these efforts, BL-760, through animal studies using both rodent and swine models employing a clinically applicable imaging system. In contrast to ICG, BL-760 fluorescence revealed a high target-to-background ratio (TBR) of the cystic duct relative to liver parenchyma 5 min after intravenous injection. During hepatic resection surgery, intrahepatic ducts were clearly highlighted, and bile leakage was easily detected. In conclusion, BL-760 has highly promising properties for intraoperative navigation during hepatobiliary surgery.
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Affiliation(s)
- Michael P Luciano
- Chemical Biology Laboratory, Center for Cancer Research , National Cancer Institute , 376 Boyles Street , Frederick , Maryland 21702 , United States
| | - Jung-Man Namgoong
- Sheikh Zayed Institute for Pediatric Surgical Innovation , Children's National Health System , 111 Michigan Avenue Northwest , Washington , D.C. 20010 , United States.,Department of Surgery , University of Ulsan College of Medicine , Asan Medical Center, 88 Olympic-ro, 43-gil , Songpa-gu, Seoul 138-736 , South Korea
| | - Roger R Nani
- Chemical Biology Laboratory, Center for Cancer Research , National Cancer Institute , 376 Boyles Street , Frederick , Maryland 21702 , United States
| | - So-Hyun Nam
- Sheikh Zayed Institute for Pediatric Surgical Innovation , Children's National Health System , 111 Michigan Avenue Northwest , Washington , D.C. 20010 , United States.,Department of Surgery , Dong-A University College of Medicine , 26 Daesingongwon-Ro , Seo-Gu, Busan 49201 , South Korea
| | - Choonghee Lee
- InTheSmart Co , Center for Medical Innovation Bld , 71 Daehak-ro , Jongro-gu, Seoul , South Korea
| | - Il Hyung Shin
- InTheSmart Co , Center for Medical Innovation Bld , 71 Daehak-ro , Jongro-gu, Seoul , South Korea
| | - Martin J Schnermann
- Chemical Biology Laboratory, Center for Cancer Research , National Cancer Institute , 376 Boyles Street , Frederick , Maryland 21702 , United States
| | - Jaepyeong Cha
- Chemical Biology Laboratory, Center for Cancer Research , National Cancer Institute , 376 Boyles Street , Frederick , Maryland 21702 , United States.,Department of Pediatrics , George Washington University School of Medicine and Health Sciences , 2300 Eye Street Northwest , Washington , D.C. 20052 , United States
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7
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Bauschke A, Altendorf-Hofmann A, Malessa C, Rohland O, Settmacher U. [Influence of bile duct anatomy on biliary complications in hepatic right lobe living donors]. Chirurg 2019; 89:222-228. [PMID: 28940029 DOI: 10.1007/s00104-017-0514-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Perioperative morbidity in the living donation of partial livers is mainly due to infections and biliary complications. Bile duct anatomy variants, in particular of the right system, are suspected to be causative. We investigated the influence of bile duct variants on the incidence of biliary donor complications in donations of the right liver lobe. We analyzed 103 donors. Twelve patients had a bile leak that required treatment. All of these were treated endoscopically without any residual defect. We did not see a central extrahepatic bile duct lesion Nagano type C. The anatomic variant Huang A3 is a challenge with respect to the surgical technique. Three of 17 patients with biliary anatomy Huang A3 developed leaks. The bile duct anatomy can be carefully evaluated by magnetic resonance cholangiopancreatography (MRCP) and intraoperative cholangiography. The anatomic variant Huang A3 warrants particular attention for the closure of the bile duct orifice.
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Affiliation(s)
- A Bauschke
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland.
| | - A Altendorf-Hofmann
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - C Malessa
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - O Rohland
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - U Settmacher
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
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Wei L, Zhang ZT, Zhu ZJ, Sun LY, Zeng ZG, Qu W, Zhang L, He EH, Xu RF, Zhou GP. A New Approach to Accomplish Intraoperative Cholangiography in Left Lateral Segmentectomy of Living Liver Donation. Ann Transplant 2019; 24:155-161. [PMID: 30886133 PMCID: PMC6439928 DOI: 10.12659/aot.915400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background There are 2 main methods of bile duct division in harvesting left lateral segment of a living donor: 1) by intraoperative cholangiography through cystic duct with cholecystectomy, or 2) by direct vision with preoperative magnetic resonance cholangiopancreatography. Here, we present a new approach to cholangiography by using the bile duct stump of the fourth liver segment (B4 stump) to achieve left lateral segmentectomy in pediatric living donor liver transplantation. Material/Methods This was a prospective study of 221 living donors who had undergone intraoperative cholangiography via the B4 stump in the course of left lateral segmentectomy. We collected and analyzed the clinical data, including the success rate of cholangiography by catheterizing the B4 stump; the associated time cost; the classification of the donor liver’s biliary anatomy; the number of bile duct orifices on the graft side; and postoperative complications involving the biliary tract. Results We were successful in catheterizing B4 stumps in all 221 patients. The mean time cost of these procedures was 7.21±3.62 minutes. Variations in the confluence of the right and left lobes were found in 58 patients (26.24%). Overall, sludge was detected in 18 cases (8.14%), gallstones were found in 3 patients (1.36%), and a polypoid gallbladder lesion was found in 1 patient (0.45%). There were 11 cases (4.98%) of bile leakage; no biliary strictures were found in the donors. Conclusions Intraoperative cholangiography via the B4 stump is an alternative procedure for living donors who undergoes left lateral segmentectomy.
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Affiliation(s)
- Lin Wei
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing, China (mainland)
| | - Zhong-Tao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing, China (mainland)
| | - Zhi-Jun Zhu
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing, China (mainland)
| | - Li-Ying Sun
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing, China (mainland)
| | - Zhi-Gui Zeng
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing, China (mainland)
| | - Wei Qu
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing, China (mainland)
| | - Liang Zhang
- Department of Anesthesia, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - En-Hui He
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Rui-Fang Xu
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Guang-Peng Zhou
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University and National Clinical Research Center for Digestive Diseases, Beijing, China (mainland)
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9
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Makki K, Chorasiya V, Srivastava A, Singhal A, Khan AA, Vij V. Analysis of caudate lobe biliary anatomy and its implications in living donor liver transplantation - a single centre prospective study. Transpl Int 2018; 31:1041-1049. [PMID: 29722074 DOI: 10.1111/tri.13272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/03/2018] [Accepted: 04/23/2018] [Indexed: 12/14/2022]
Abstract
Biliary complications are a significant cause of morbidity after living donor liver transplant (LDLT). Bile leak may occur from bile duct (anastomotic site in recipient and repaired bile duct stump in donor), cystic duct stump, cut surface pedicles or from divided caudate ducts. The first three sites are amenable to post-operative endoscopic stenting as they are in continuation with biliary ductal system. However, leaks from divided isolated caudate ducts can be stubborn. To minimize caudate duct bile leaks, it is important to understand the anatomy of hilum with attention to the caudate lobe biliary drainage. This single-centre prospective study of 500 consecutive LDLTs between December 2011 and December 2016 aims to define the biliary anatomy of the caudate lobe in liver donors based on intraoperative cholangiograms (IOCs) with special attention to crossover caudate ducts and to study their implications in LDLT. Caudate ducts were identified in 468 of the 500 IOCs. Incidence of left-to-right crossover drainage was 61.37% and right to left was 21.45%. Incidence of bile leak in donors was 0.8% and in recipients was 2.2%. Proper intraoperative identification and closure of divided isolated caudate ducts can prevent bile leak in donors as well as recipients.
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Affiliation(s)
- Kausar Makki
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Vishal Chorasiya
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Ajitabh Srivastava
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Ashish Singhal
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Arif Ali Khan
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Vivek Vij
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
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10
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Safwan M, Nagai S, Collins K, Rizzari M, Yoshida A, Abouljoud M. Impact of abdominal shape on living liver donor outcomes in mini-incision right hepatic lobectomy: Comparison among 3 techniques. Liver Transpl 2018; 24:516-527. [PMID: 29281863 DOI: 10.1002/lt.25001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/31/2017] [Accepted: 12/03/2017] [Indexed: 02/07/2023]
Abstract
Although minimally invasive techniques for living donor hepatectomy have been developed, the surgical feasibility and limitations remain to be elucidated. The risks and outcomes involved need to be better understood prior to their widespread application. The aim of this study was to assess feasibility of minimally invasive donor hepatectomy by reviewing our experience. A total of 99 living donor liver transplantations performed between 2000 and 2016 were retrospectively reviewed. All 99 living liver donors underwent right hepatectomy. The breakdown of the techniques is as follows: the standard technique in 33 patients; the laparoscopic-assisted minilaparotomy technique (hybrid technique group) in 19 patients; and the upper midline incision technique without laparoscopic assistance (minilaparotomy group) in 47 patients. An association between donor operative outcomes and body habitus, such as body mass index (BMI), abdominal truncal depth (approximated by celiac axis [CA] depth ratio), and umbilical circumference (UC) were assessed. Perioperative factors were compared between the standard technique and the minimally invasive technique. The minilaparotomy group had significantly shorter operative time (P = 0.046) and hospital stay (P = 0.005) than the standard technique group. Postoperative complication rates were similar between the 3 groups (P = 0.16). In the minilaparotomy group, greater BMI (P = 0.02), CA depth ratio (P = 0.04), and UC (P = 0.004) were found to be risk factors for postoperative complications. In the minilaparotomy group, CA depth ratio > 0.41, UC > 90 cm, and BMI > 30 kg/m2 were significantly associated with longer operative time and hospital stay. In the standard technique group, none of the body size factors were associated with postoperative outcomes. In conclusion, the minilaparotomy technique is safe and feasible, though technical difficulties may be encountered when performed on donors with larger body habitus. Ongoing efforts are required to ensure living donor safety. Liver Transplantation 24 516-527 2018 AASLD.
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Affiliation(s)
- Mohamed Safwan
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Kelly Collins
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Michael Rizzari
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Atsushi Yoshida
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
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11
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Yassen AM, Elsarraf WR, Elmorshedi MA, Abdel Wahab M, Salah T, Sultan AM, Elghawalby AN, Elshobari MM, Elsadany M, Zalata K, Shiha U. Short-term effects of extracorporeal graft rinse versus circulatory graft rinse in living donor liver transplantation. A prospective randomized controlled trial. Transpl Int 2017; 30:725-733. [PMID: 28403531 DOI: 10.1111/tri.12968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 12/12/2016] [Accepted: 04/06/2017] [Indexed: 12/20/2022]
Abstract
Living donor liver transplantation has shorter cold ischemia time, less preservative volume, and lower metabolic load compared to transplantation from deceased donors. We investigated the impact of rinsing the graft contents into the systemic circulation on operative course and postoperative outcomes. Donors had right hepatectomy, and grafts were preserved with cold histidine-tryptophan-ketoglutarate solution. On ending portal vein anastomosis, grafts were flushed by patient's portal blood either through incompletely anastomosed hepatic vein (extracorporeal rinse group, EcRg, n = 40) or into systemic circulation (circulatory rinse group, CRg, n = 40). The primary outcome objective was the lowest mean arterial blood pressure within 5 min after portal unclamping as a marker for postreperfusion syndrome (PRS). Secondary objectives included hemodynamics and early graft's and patient's outcomes. Within 5 min postreperfusion, mean arterial blood pressure was significantly lower in the CRg compared to the EcRg, yet this was clinically insignificant. Postoperative graft functions, early biliary and vascular complications, and three-month survival were comparable in both groups. Rinsing the graft into the circulation increased the incidence of PRS without significant impact on early graft or patient outcome in relatively healthy recipients.
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Affiliation(s)
- Amr M Yassen
- Department of Anesthesia and Intensive Care, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Waleed R Elsarraf
- Department of Anesthesia and Intensive Care, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Mohamed A Elmorshedi
- Department of Anesthesia and Intensive Care, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Mohamed Abdel Wahab
- Department of Surgery, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Tarek Salah
- Department of Surgery, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Ahmed M Sultan
- Department of Surgery, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Ahmed N Elghawalby
- Department of Surgery, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Mohamed M Elshobari
- Department of Surgery, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Mohamed Elsadany
- Department of Hepatology, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Khaled Zalata
- Department of Pathology, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
| | - Usama Shiha
- Department of Radiology, Gastroenterology Surgical Center, Mansoura University, Mansoura, Dakahlia, Egypt
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12
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Kim SH, Lee EC, Lee SD, Park SJ. Ligation and cut as a method for bile duct division in living donor right hepatectomy. Liver Transpl 2017; 23:448-456. [PMID: 27809402 DOI: 10.1002/lt.24670] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/04/2016] [Accepted: 10/08/2016] [Indexed: 02/07/2023]
Abstract
The importance of bile duct division cannot be overemphasized in living donor surgery. Ligation and cut (LC) as a method for bile duct division in living donor right hepatectomy (LDRH) has never been reported. The purpose of this study was to introduce the LC method of bile duct division in LDRH. All LDRH donors were identified through a prospectively maintained database at the authors' institution between September 2009 and March 2013, and the 2 methods, LC and cut and oversewing (CO), were compared both in terms of donor and recipient outcomes of right lobe living donor liver transplantation. In the LC method, after complete parenchymal transection, the right hepatic duct was dissected in the Glisson's sheath and ligated just at the right side of the confluence, and then the right side of the ligature was cut. The LC and CO methods were performed in 109 and 134 donors, respectively. Bile duct division time (P < 0.001) and operative time (P < 0.001) were significantly shorter in the LC group than in the CO group. With a median follow-up of 60.2 months, biliary complication rate was lower in the LC group than in the CO group (0% versus 5.2%; P = 0.01), but with no significant difference between the recipient groups. All donors made a complete recovery. In conclusion, the bile ducts of living donors can be dissected safely from the Glisson's sheath, and the LC method facilitates bile duct division and has a lower incidence of biliary complication in LDRH without compromising the recipient outcomes. Liver Transplantation 23 448-456 2017 AASLD.
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Affiliation(s)
- Seong Hoon Kim
- Organ Transplantation Center, Center for Liver Cancer, National Cancer Center, Ilsandong-gu, Goyang-si Gyeonggi-do, South Korea
| | - Eung Chang Lee
- Organ Transplantation Center, Center for Liver Cancer, National Cancer Center, Ilsandong-gu, Goyang-si Gyeonggi-do, South Korea
| | - Seung Duk Lee
- Organ Transplantation Center, Center for Liver Cancer, National Cancer Center, Ilsandong-gu, Goyang-si Gyeonggi-do, South Korea
| | - Sang Jae Park
- Organ Transplantation Center, Center for Liver Cancer, National Cancer Center, Ilsandong-gu, Goyang-si Gyeonggi-do, South Korea
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13
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El Shobary M, Salah T, El Nakeeb A, Sultan AM, Elghawalby A, Fathy O, Wahab MA, Yassen A, Elmorshedy M, Elkashef WF, Shiha U, Elsadany M. Spray Diathermy Versus Harmonic Scalpel Technique for Hepatic Parenchymal Transection of Living Donor. J Gastrointest Surg 2017; 21:321-329. [PMID: 27798785 DOI: 10.1007/s11605-016-3312-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/13/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Liver parenchymal transection is the most invasive and challenging part in the living donor operation. The study was planned to compare the safety, efficacy, and outcome of harmonic scalpel versus spray diathermy as a method of parenchymal liver transection in donor hepatectomy. PATIENT AND METHOD Eighty consecutive patients, who were treated by living donor liver transplantation (LDLT), were included in the study. The study population was divided into two groups according to the method of liver transection: group A by harmonic scalpel (HS) and group B by spray diathermy (SD). The primary outcome was the volume of blood loss during transection. Secondary outcomes were time of transection, number of ligatures needed during transection, pathological changes at cut surface, postoperative morbidities, cost, and hospital stay RESULTS: Blood loss during overall liver transection and in each zone was significantly less in the SD than in the HS group (P = 0.015). The number of ligatures was significantly less in the SD than in the HS group (P = 0.0001). The SD group had significantly higher level of serum bilirubin, serum glutamic pyruvic transaminase (SGPT), and international normalized ratio (INR) levels on postoperative day 3 than the HS group. Lateral tissue coagulation and hepatic necrosis are significantly less in HS group. The overall incidence of postoperative morbidities was the same in both groups. The cost was higher in HS group than SD group (US$760 vs. US$40 P = 0.0001). CONCLUSION Spray diathermy is an effective method of parenchymal transection with significantly lower blood loss and lower cost compared to HS with no increase in morbidity. HS is associated with earlier recovery of liver functions.
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Affiliation(s)
- Mohamed El Shobary
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Tarek Salah
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Ayman El Nakeeb
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt.
| | - Ahmad M Sultan
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Ahmed Elghawalby
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Omar Fathy
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Mohamed Abdel Wahab
- Gastrointestinal Surgery and Liver Transplantation Unit, Gastroenterology Surgical Center, Mansoura University, Daqahlia, 35516, Egypt
| | - Amro Yassen
- Anesthesia and Intensive Care Department, Mansoura Faculty of Medicine, Mansoura University, Daqahlia, Egypt
| | - Mohamed Elmorshedy
- Anesthesia and Intensive Care Department, Mansoura Faculty of Medicine, Mansoura University, Daqahlia, Egypt
| | - Wagdi F Elkashef
- Pathology Department, Mansoura Faculty of Medicine, Mansoura University, Daqahlia, Egypt
| | - Usama Shiha
- Radiology Department, Gastroenterology Surgical Center, Mansoura University, Daqahlia, Egypt
| | - Mohamed Elsadany
- Internal Medicine Department, Mansoura Faculty of Medicine, Mansoura University, Daqahlia, Egypt
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14
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Bae SJ, Han DH, Choi GH, Choi JS. The Role of Bile Duct Probe for Bile Duct Division during Donor Right Hemihepatectomy. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.4.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Soong June Bae
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dai Hoon Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Gi Hong Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sub Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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15
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Braun HJ, Ascher NL, Roll GR, Roberts JP. Biliary complications following living donor hepatectomy. Transplant Rev (Orlando) 2016; 30:247-52. [PMID: 27531698 DOI: 10.1016/j.trre.2016.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 04/26/2016] [Accepted: 07/13/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) has become increasingly common in an effort to increase organ availability for the treatment of end-stage liver disease. Donor safety is a primary concern in LDLT. The majority of complications experienced by living donors are infectious or biliary in nature. The purpose of this paper was to review the existing literature on biliary complications in living donors. METHODS Studies were eligible for inclusion if they were published in English between 2006-present, focused on adult-to-adult LDLT, and were available via PubMed/MEDLINE. RESULTS A total of 33 studies reporting outcomes from 12,653 donors (right lobe: 8231, left lobe: 4422) were included. Of 33 studies, 12 reported outcomes from right lobe donors, 1 from left lobe donors, 14 compared left and right, and 6 focused specifically on biliary complications. A total of 830 biliary complications (6.6%) were reported, with 75 donors requiring re-operation for biliary complications and 1 donor death attributed to biliary complications. CONCLUSION Although bile leaks and strictures are still relatively common following living donor hepatectomy, the majority of complications are minor and resolve with conservative measures. Approximately 6% of living donors will experience a biliary complication and, of these 6%, approximately 9% (total of 0.6% of donors) will require operative management of the biliary complication.
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Affiliation(s)
- Hillary J Braun
- School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Nancy L Ascher
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Garrett R Roll
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - John P Roberts
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
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16
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Jung DH, Hwang S, Ha TY, Song GW, Kim KH, Ahn CS, Moon DB, Park GC, Jung BH, Kwang SH, Lee SG. Long-term outcome of ischemic type biliary stricture after interventional treatment in liver living donors: a report of two cases. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2015; 19:71-4. [PMID: 26155280 PMCID: PMC4494080 DOI: 10.14701/kjhbps.2015.19.2.71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 01/28/2015] [Accepted: 02/14/2015] [Indexed: 11/17/2022]
Abstract
The wall of normal proximal bile duct is occasionally thin with close approximation to the right hepatic artery. Thus, isolation of this hepatic artery can result in excessive weakening of the remnant proximal bile duct wall during hemiliver graft harvest. This type of injury can induce ischemic stricture of the donor common bile duct. This study aimed to review the clinical sequences of such ischemic type donor bile duct injuries primarily managed with endoscopic and radiological interventional treatments. A retrospective review of medical records was performed for two living donors who suffered from ischemic type donor bile duct injury. They were followed up for more than 10 years. The right and left liver grafts were harvested from these two donors. Bile duct anatomy was normal bifurcation in one and anomalous branching in the other. Bile duct stenosis was detected in them at 2 weeks and 1 week after liver donation. They underwent endoscopic balloon dilatation and temporary stent (endoscopic retrograde biliary drainage tube) insertion. After keeping the tube for 2 months, the tube was successfully removed in one donor. However, endoscopic treatment was not successful, thus additional radiological intervention was necessary in the other donor. On follow-up over 10 years, they are doing well so far with no recurrence of biliary stricture. Based on our limited experience, interventional treatment with subsequent long-term follow-up appears to be an essential and choice treatment for ischemic type biliary stricture occurring in liver living donors.
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Affiliation(s)
- Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo-Hyun Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Hwa Kwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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