Multiple Graft Bile Ducts Do Not Affect the Postoperative Outcomes of Right Lobe Living Donor Liver Transplantation

Multiple graft duct openings are associated with a high incidence of biliary complications (BCs), and biliary reconstruction for multiple graft bile ducts (BDs) remains a surgical challenge during living donor liver transplantation (LDLT). In particular, biliary reconstruction using "high biliary radicals (HBR)" of recipients for multiple graft BDs has a high probability of BCs. Herein, we analyzed outcomes by retrospectively reviewing 283 patients who underwent right lobe LDLT from January 2013 to September 2019. In total, 112 LDLT procedures using grafts with multiple BDs have been performed under our policies. In recent cases with 2 orifices located on the same hilar plate, we did dunking with a mucosal eversion technique instead of ductoplasty. When 2 orifices are located far apart on different hilar plates, we attempted to perform separate duct-to-duct anastomosis (DDA) using HBR of the recipient instead of hepaticojejunostomy. Among patients with multiple graft BDs, 20 underwent ductoplasty, 50 were treated using dunking with mucosal eversion technique, and 40 underwent separate DDA using HBR (HBR group). The incidence rates of biliary leakage and stricture were 8.9% and 10.7% in the multiple BD group, respectively, congruent with the outcomes of the single BD group. In subgroup analysis, we compared clinical outcomes between the HBR and single BD groups; the incidence of BCs in the HBR group was 15.0%, comparable to that of the single BD group. In conclusion, multiple graft BDs do not negatively impact the BC rate compared with single-graft BD when applying our technique to prevent BCs.

Technical Refinement to Prevent Hepatic Outflow Disturbance in Right Lobe Living Donor Liver Transplantation: The New Simplified One-Orifice Venoplasty Technique

Middle hepatic vein (MHV) reconstruction is often essential to avoid hepatic congestion and serious graft dysfunction in living donor liver transplantation (LDLT). This article introduces the evolution of our MHV reconstruction technique and the excellent outcomes of a new simplified one-orifice venoplasty. We compared clinical outcomes among 3 types of one-orifice techniques through a retrospective review of 378 recipients who underwent LDLT using a modified right lobe graft at our institution from January 2008 to December 2018; group I (n = 34) received separate outflow reconstruction, group II (n = 166) received the one-orifice technique to create a wider single outflow with patchwork, and group III (n = 178) received the more simplified one-orifice technique in which neo-MHV was reconstructed into the right hepatic vein without patch venoplasty. Patient demographic characteristics did not differ significantly among the 3 groups, but cold ischemic time and operative time in groups II and III were significantly shorter than those in group I. Moreover, the early patency rates of MHV in groups II and III were higher than those in group I. In particular, group I received an MHV or right hepatic vein stenting more frequently than group II or III during the early posttransplant period. In conclusion, this new simplified one-orifice technique could be an effective method to overcome technical difficulties and the outflow disturbance during right lobe LDLT without complex benchwork to create a large outflow.

Renal safety of tenofovir disoproxil fumarate and entecavir in liver transplant patients: a nationwide Korean registry study

BACKGROUND AND AIMS

Tenofovir disoproxil fumarate (TDF) and entecavir (ETV) have been recommended after liver transplantation to prevent recurrence of hepatitis B virus infection. Despite its proven efficacy, the renal safety of TDF has not been established in liver transplant recipients. We aimed to compare the effects of TDF and ETV on renal function in liver transplant recipients and to evaluate risk factors for renal dysfunction after liver transplantation.

METHODS

This is a retrospective, observational multicenter study of data from the Korean Organ Transplantation Registry. We included adults who underwent liver transplantation for hepatitis B virus-related complications from April 2014 to December 2017 and received TDF or ETV post-transplantation. Renal dysfunction was defined as an estimated glomerular filtration rate decline by at least 20% from baseline (1 month post-transplantation). Median duration of follow-up was 29 months (interquartile range 19-42).

RESULTS

A total of 804 liver transplant patients were included. The cumulative probability of renal dysfunction was significantly higher in the TDF group than in the ETV group. Multivariable analysis confirmed that TDF was independently associated with an increased risk of renal dysfunction (hazard ratio = 1.47, 95% confidence interval 1.12-1.92; p = 0.005). Independent risk factors for renal dysfunction included older age, worse baseline renal function, and low body mass index. Overall survival rate was significantly lower in patients with renal dysfunction than in those without.

CONCLUSIONS

In this nationwide study, the use of TDF was associated with an increased risk of renal dysfunction, when compared with ETV.

Predicting the Recurrence of Hepatocellular Carcinoma after Primary Living Donor Liver Transplantation Using Metabolic Parameters Obtained from 18F-FDG PET/CT

This study evaluated the prognostic value of metabolic parameters based on the standardized uptake value (SUV) normalized by total body weight (bwSUV) and by lean body mass (SUL) measured on ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) for predicting tumor recurrence after primary living donor liver transplantation (LDLT) in patients with hepatocellular carcinoma (HCC) without transplantation locoregional therapy. This retrospective study enrolled 49 patients with HCC. The maximum tumor bwSUV (T-bwSUVmax) and SUL (T-SULmax) were measured on PET. The maximum bwSUV (L-bwSUVmax), mean bwSUV (L-bwSUVmean), maximum SUL (L-SULmax), and mean SUL (L-SULmean) were measured in the liver. All metabolic parameters were evaluated using survival analyses and compared to clinicopathological factors. Tumor recurrence occurred in 16/49 patients. Kaplan–Meier analysis revealed that all metabolic parameters were significant (p < 0.05). Univariate analysis revealed that prothrombin-induced by vitamin K absence or antagonist-II; T-stage; tumor number; tumor size; microvascular invasion; the Milan criteria, University of California, San Francisco (UCSF), and up-to-seven criteria; T-bwSUVmax/L-bwSUVmean; T-SULmax; T-SULmax/L-SULmax; and T-SULmax/L-SULmean were significant predictors. Multivariate analysis revealed that the T-SULmax/L-SULmean (hazard ratio = 115.6; p = 0.001; cut-off, 1.81) and UCSF criteria (hazard ratio = 172.1; p = 0.010) were independent predictors of tumor recurrence. SUL-based metabolic parameters, especially T-SULmax/L-SULmean, were significant, independent predictors of HCC recurrence post-LDLT.

A comparative study of postoperative outcomes between minimally invasive living donor hepatectomy and open living donor hepatectomy: The Korean organ transplantation registry

BACKGROUND

This study evaluated the safety and effectiveness of minimally invasive living donor hepatectomy in comparison with the open procedure, using Korean Organ Transplantation Registry data.

METHODS

We reviewed the prospectively collected data of all 1,694 living liver donors (1,071 men, 623 women) who underwent donor hepatectomy between April 2014 and December 2017. The donors were grouped on the basis of procedure type to the minimally invasive procedure group (n = 304) or to the open procedure group (n = 1,390) and analyzed the relationships between clinical data and complications.

RESULTS

No donors died after the procedure. The overall complication rates after operation in the minimally invasive procedure group and the open procedure group were 6.2% and 3.5%, respectively. Biliary complications were the most frequent events in both groups (minimally invasive procedure group, 2.4%; open procedure group, 1.6%). The majority of complications occurred within 7 days after surgery in both groups. The duration of hospitalization was shorter in the minimally invasive procedure group than in the open procedure group (9.04 ± 3.78 days versus 10.29 ± 4.01 days; P < .05).

CONCLUSION

Based on its similar outcomes in our study, minimally invasive donor hepatectomy cannot be an alternative option compared with the open procedure method. To overcome this, we need to ensure better surgical safety, such as lower complication rate and shorter duration of hospitalization.

Outcomes after liver transplantation in Korea: Incidence and risk factors from Korean transplantation registry

BACKGROUND/AIMS

To analyze the incidence and risk factors of outcomes after liver transplantation (LT) in the Korean population.

METHODS

This study analyzed data from the liver cohort of Korean Organ Transplantation Registry (KOTRY) who had LT between May 2014 and December 2017. Study measures included the incidence of post-LT outcomes in recipients of living donor LT (LDLT) and deceased donor LT (DDLT). Cox multivariate proportional hazards model was used to determine the potential risk factors predicting the outcomes.

RESULTS

A total of 2,563 adult recipients with LT (LDLT, n=1,956; DDLT, n=607) were included, with mean±standard deviation age of 53.9±8.9 years, and 72.2% were male. The post-LT outcomes observed in each LDLT and DDLT recipients were death (4.0% and 14.7%), graft loss (5.0% and 16.1%), rejection (7.0% and 12.0%), renal failure (2.7% and 13.8%), new onset of diabetes (12.5% and 15.4%), and hepatocellular carcinoma (HCC) recurrence (both 6.7%). In both LDLT and DDLT recipients, the most common post-LT complications were renal dysfunction (33.6% and 51.4%), infection (26.7% and 48.4%), and surgical complication (22.5% and 23.9%). Incidence of these outcomes were generally higher among recipients of DDLT than LDLT. Multivariate analysis indicated recipient age and DDLT as significant risk factors associated with death and graft loss. DDLT and ABO incompatible transplant were prognostic factors for rejection, and HCC beyond Milan criteria at pre-transplant was a strong predictor of HCC recurrence.

CONCLUSION

This study is a good indicator of the post-LT prognosis in the Korean population and suggests a significant burden of post-LT complications.

Pre-treatment absolute lymphocyte count predicts for improved survival in human papillomavirus (HPV)-driven oropharyngeal squamous cell carcinoma

BACKGROUND

The prognostic value of pretreatment complete blood count (CBC) data, including absolute lymphocyte count (ALC) and the neutrophil-to-lymphocyte ratio (NLR), has been reported for many diseases with decreased ALC and increased absolute neutrophil count (ANC) and NLR values correlating with worse outcomes. There is minimal data relating these hematologic parameters to oropharyngeal squamous cell carcinoma (OPSCC) prognosis. This study evaluates the prognostic value of pretreatment CBC data in OPSCC on overall survival (OS) and progression-free survival (PFS) in relation to HPV status.

METHODS

A single-institutional retrospective review of patients with pretreatment hematologic data who received radiation for OPSCC was performed. Univariate and multivariate (UVA/MVA) Cox proportional hazard regression analyses were performed to identify prognostic variables. Translational studies related outcomes to the degree of tumor-infiltrating lymphocytes (TILs) in histologic specimens.

RESULTS

From 2007 to 2018, 201 patients were treated for OPSCC. Median follow-up was 40 months. 3-year OS was 86.2% in the HPV-positive cohort, 46.3% for HPV-negative. Median NLR was 3.04. NLR ≥ 3 was associated with worse PFS (HR 1.67, p = 0.044. In the subset of 158 HPV + patients, MVA revealed increasing ALC to be associated with improved OS (HR 0.53; p = 0.040) and PFS (HR = 0.48; p = 0.0075). On UVA, high-TIL infiltration at diagnosis was associated with improved OS.

CONCLUSION

In a cohort of HPV + OPSCC patients, increasing ALC is associated with improved OS and PFS. Our study is the first to identify pre-treatment ALC as an independent prognostic factor in HPV-associated OPSCC.

A case of coronavirus disease 2019-infected liver transplant donor

Coronavirus disease 2019 (COVID-19) is a novel infectious disease that continues to spread on a global scale. There has been growing concern about donor-derived transmissions of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Herein, we present the case of a patient who underwent ABO-incompatible living donor liver transplantation without knowing that the liver donor was infected with COVID-19 during the donation procedure. In this case, the donor-derived transmission to the recipient was not identified, and the liver donor was found to be recovering from a COVID-19 infection. The donor-derived transmission was not identified.

New-onset diabetes after adult liver transplantation in the Korean Organ Transplantation Registry (KOTRY) study

BACKGROUND

New-onset diabetes after transplantation (NODAT) is a serious complication following liver transplantation (LT). The present study aimed to investigate the incidence of and risk factors for NODAT using the Korean Organ Transplantation Registry (KOTRY) database.

METHODS

Patients with history of pediatric transplantation (age ≤18 years), re-transplantation, multi-organ transplantation, or pre-existing diabetes mellitus were excluded. A total of 1,919 non-diabetic adult patients who underwent a primary LT between May 2014 and December 2017 were included. Risk factors were identified using Cox regression analysis.

RESULTS

NODAT occurred in 19.7% (n=377) of adult liver transplant recipients. Multivariate analysis showed steroid use, increased age, and high body mass index (BMI) in recipients, and implantation of a left-side liver graft was closely associated with NODAT in adult LT. In living donor liver transplant (LDLT) patients (n=1,473), open donor hepatectomy in the living donors, steroid use, small for size liver graft (graft to recipient weight ratio ≤0.8), increased age, and high BMI in the recipient were predictive factors for NODAT. The use of antimetabolite and basiliximab induction reduced the incidence of NODAT in adult LT and in adult LDLT.

CONCLUSIONS

Basiliximab induction, early steroid withdrawal, and antimetabolite therapy may prevent NODAT after adult LT. High BMI or advanced age in liver recipients, open donor hepatectomy in living donors, and small size liver graft can predict the occurrence of NODAT after adult LT or LDLT.

Safety and Efficacy of Living Donor Hepatectomy Without Systemic Heparinization: Short- and Long-Term Outcomes

There is no consensus regarding the use of systemic heparin, and long-term outcomes of living donor hepatectomy (LDH) without systemic heparinization have not yet been determined. This study was performed to determine whether systemic heparinization can be omitted during LDH, with a focus on donor safety and long-term outcomes. We retrospectively analyzed the outcomes of 175 cases of LDH performed in our institution between January 2011 and December 2014: group I (n = 79) received systemic heparinization, whereas group II (n = 96) did not, but liver graft was flushed with a heparinized perfusate. Postoperative bleeding requiring blood transfusion or intervention was more frequent in group I than in group II (P = .028). The decreases in donor hemoglobin and hematocrit levels, and platelet count during the early postoperative period, were greater in group I than in group II. In multivariate analysis, systemic heparin was the only independent risk factor for blood transfusion (odds ratio [OR] = 5.114; 95% confidence interval [CI]: 1.201-21.775; P = .027) and significant postoperative bleeding (OR = 7.731; 95% CI: 1.345-44.429; P = .022) after LDH. Most postoperative complications including graft vascular thrombosis were similar between the 2 groups, as was the survival rate, and neither graft loss due to vascular thrombosis nor non-anastomotic biliary stricture was evident. In conclusion, omission of systemic heparinization during LDH is a feasible and safe option without adverse effects.

Feasibility of Dual Living Donor Liver Transplantation From Donors With Complex Portal Vein Variations

Living donor liver transplantation (LDLT) from donors with complex portal vein anomalies has been considered a challenging procedure because vasculobiliary variations of the donor's liver may lead to significant increases in donor and recipient complications. The use of donors with anatomic variations may be considered under the accurate preoperative planning if a more suitable donor is not available. We report a successful dual LDLT for 2 donors with portal vein anomaly to overcome the small-for-size graft syndrome and secure donor safety. A 62-year-old man was referred to our institution for liver transplant because of hepatitis B-related liver cirrhosis with hepatocellular carcinoma. The only available donors were his son and his daughter-in-law, one with type IV portal venous anatomic variation and the other with type III variation. Neither of the 2 available donors were suitable as a single donor because of the complexity of the portal vein reconstruction and the donor's safety. Therefore, the decision was made to perform LDLT using dual graft, and we planned to harvest the right posterior sector graph from the first donor together with the left lobe graft of the second donor. Donor hepatectomy and recipient total hepatectomy were performed in the usual manner. He has recovered well with normal graft function, and there has been no tumor recurrence after dual LDLT. Dual graft LDLT using right posterior sector and left lobe graft could be undertaken successfully to overcome the small-for-size graft syndrome and secure the safety of donors in cases with the complex portal vein anomalies.

Novel Method for Reconstructing Multiple Graft Bile Ducts During Right Lobe Living Donor Liver Transplant: Dunking With Mucosal Eversion Technique

BACKGROUND

Multiple graft bile ducts (BDs) and anastomoses have been considered as risk factors for biliary complications after living donor liver transplant (LDLT). Various surgical techniques have been introduced, and most surgeons perform unification ductoplasty for multiple adjacent BDs during LDLT. However, this could cause hemobilia and is difficult to perform when 2 ductal orifices are far apart or show a size discrepancy.

METHODS

Here, we introduce our novel reconstruction technique for multiple adjacent graft BDs and discuss its effects on postoperative outcomes compared with ductoplasty. We compared the clinical outcomes of 2 biliary reconstruction techniques by retrospectively reviewing 58 recipients who underwent LDLT with right lobe grafts using these 2 techniques at our institution between January 2013 and September 2018: group 1 (n = 20) received ductoplasty, and group 2 (n = 38) was treated with dunking with mucosal eversion technique.

RESULTS

Overall biliary complication rates were 20.0% in group 1 and 10.5% in group 2 (P = .32). Biliary stricture in group 2 was not frequent compared with that in group 1 (7.9% vs 15.0%, P = .398). Moreover, incidence of biliary stricture in group 2 was not different than that in the group using graft with single BD during the same period (P > .624).

CONCLUSIONS

Our novel technique could be a useful method for reconstructing adjacent BDs in LDLT and the best alternative to ductoplasty. Moreover, it seems to be a reasonable option when 2 orifices are far apart or show a size discrepancy.

Hepatitis B Prophylaxis after Liver Transplantation in Korea: Analysis of the KOTRY Database

BACKGROUND

Prophylaxis for hepatitis B virus (HBV) recurrence is essential after liver transplantation (LT) in HBV-associated recipients. We conducted real-world analysis of HBV prophylaxis after LT in the Korean population.

METHODS

Korean Organ Transplantation Registry (KOTRY) database and additionally collected data (n = 326) were analyzed with special reference to types of HBV prophylaxis.

RESULTS

The study cohort comprised 267 cases of living-donor LT and 59 cases of deceased-donor LT. Hepatocellular carcinoma (HCC) was diagnosed in 232 (71.2%) of these subjects. Antiviral agents were used in 255 patients (78.2%) prior to LT. HBV DNA was undetectable in 69 cases (21.2%) and detectable over wide concentrations in the other 257 patients (78.8%) prior to LT. Polymerase chain reaction analysis of the store blood samples detected HBV DNA in all patients, with 159 patients (48.9%) showing concentrations > 100 IU/mL. Post-transplant HBV regimens during the first year included combination therapy in 196 (60.1%), hepatitis B immunoglobulin (HBIG) monotherapy in 121 (37.1%), and antiviral monotherapy in 9 (2.8%). In the second post-transplant year, these regimens had changed to combination therapy in 187 (57.4%), HBIG monotherapy in 112 (34.4%), and antiviral monotherapy in 27 (8.3%). Trough antibody to hepatitis B surface antigen titers > 500 IU/mL and >1,000 IU/mL were observed in 61.7% and 25.2%, respectively. The mean simulative half-life of HBIG was 21.6 ± 4.3 days with a median 17.7 days. Up to 2-year follow-up period, HCC recurrence and HBV recurrence developed in 18 (5.5%) and 6 (1.8%), respectively. HCC recurrence developed in 3 of 6 patients with HBV recurrence.

CONCLUSION

Combination therapy is the mainstay of HBV prophylaxis protocols in a majority of Korean LT centers, but HBIG was often administered excessively. Individualized optimization of HBIG treatments using SHL is necessary to adjust the HBIG infusion interval.

Shift in Sympathovagal Balance Toward Parasympathetic Predominance Is Associated With Attenuation of Portal Hyperperfusion in Cirrhotic Recipients Undergoing Living Donor Liver Transplant

BACKGROUND

The autonomic innervation to a liver graft remains lost up to 1 year after liver transplant. Therefore, we investigated the effects of recipients' autonomic nervous activity on the extent of portal hyperperfusion of a partial liver graft in the absence of the autonomic innervation.

METHODS

A total of 31 cirrhotic recipients undergoing right lobe living donor liver transplant were analyzed. Following a 10-minute absence of surgical stimulation after hepatic artery and bile duct reconstruction, the electrocardiogram and blood pressure waveforms were recorded for 5 minutes. Low-frequency (LF) and high-frequency (HF) powers and their ratio (LF/HF) were calculated using fast Fourier transform from the electrocardiogram waveform. A decrease in LF/HF represents a shift in sympathovagal balance toward parasympathetic predominance. Then, portal venous (PVF) and hepatic arterial (HAF) blood flows were measured in mL/min per 100 g of liver weight using spectral Doppler ultrasonography. A decrease in their ratio (PVF/HAF) represents attenuation of portal hyperperfusion.

RESULTS

The medians of the PVF and HAF were 349 and 27 mL/min/100 g liver weight with interquartile ranges of 272 to 617 mL/min/100 g liver weight and 22 to 41 mL/min/100 g liver weight, respectively, yielding a median of the PVF/HAF of 13.7 (interquartile range, 8.5-21.3). The median of LF/HF was 0.67 (interquartile range, 0.16-1.45). With a reduction in LF/HF, PVF/HAF decreased according to an S-curve regression model between them (PVF/HAF=e^{2.743+-0.031LF/HF},adjustedR²=0.129,P=0.027).

CONCLUSION

A shift in sympathovagal balance toward parasympathetic predominance is associated with attenuation of portal hyperperfusion in a partial liver graft.

Comparison of hepatic artery reconstruction using surgical loupe and operating microscope during living donor liver transplantation focusing on the beginner's point

Backgrounds/Aims

Hepatic artery (HA) reconstruction during living donor liver transplantation (LDLT) has been performed by experienced microsurgeons with operative microscope in most centers. However, it takes long time to learn the skills and so, to simplify this procedure, transplant surgeons recently performed this procedure using surgical loupe.

Methods

This study retrospectively reviewed outcomes of 237 LDLTs at our institution from January 2012 to October 2016. In group I, HA reconstruction was performed under operative microscope by an experienced microsurgeon and in group II, it was performed using surgical loupe by a transplant surgeon with little experience for arterial anastomosis.

Results

There was no difference in most perioperative outcomes between two groups except mean time required for HA reconstruction (24.2±4.3 vs. 20.9±6.9 minutes, p=0.001). Multivariable regression modeling to adjust for baseline differences showed that the use of surgical loupe was not associated with either HA thrombosis or intraoperative HA revision rate.

Conclusions

HA reconstruction under surgical loupe can be performed simply and yields results as good as with operative microscopy, even when the transplant surgeon has less experience with HA anastomosis.

Simplified Unification Patch Venoplasty for Anomalous Portal Vein Branching in Living Donor Liver Transplantation With Right Lobe Graft

Double portal vein (PV) branches during living donor liver transplantation (LDLT) with right lobe grafts have been considered challenging both in terms of donor safety and the complexity of vascular reconstruction in the recipient. Herein, we describe our experience with 24 adult LDLT recipients during which we employed unification patch venoplasty to reconstruct right lobe grafts with double PV orifices. We retrospectively reviewed the outcomes of 195 adult LDLT recipients receiving right lobe grafts, including 24 cases of adult LDLT recipients in which unification patch venoplasty was used to treat double PVs from January 2010 to June 2015. The anomalous portal vein branches of the donors were of type II in 7 cases (29.2%), type III in 15 cases (62.5%), and type IV in 2 cases (8.3%). We used propensity score matching analysis to compare the clinical outcomes of these recipients with those of 59 recipients who underwent adult LDLT using right lobe grafts with normal PVs in the same period. Intraoperative PV stenting was necessary in 2 (8.3%) of the 24 recipients undergoing unification patch venoplasty. During the follow-up period, all PVs remained patent until death or censoring. No significant difference in terms of postoperative vascular complications was evident between the 2 groups. Moreover, no major complications requiring reoperation or endoscopic and/or radiologic intervention developed in any of the 24 living donors with double PVs. In conclusion, our simplified unification patch venoplasty could be safe and feasible when used to reconstruct double PV orifices in right lobe LDLT from donors with complex PV anomalies.

Donor safety in living donor liver transplantation: The Korean organ transplantation registry study

Major concerns about donor safety cause controversy and limit the use of living donor liver transplantation to overcome organ shortages. The Korean Organ Transplantation Registry established a nationwide organ transplantation registration system in 2014. We reviewed the prospectively collected data of all 832 living liver donors who underwent procedures between April 2014 and December 2015. We allocated the donors to a left lobe group (n = 59) and a right lobe group (n = 773) and analyzed the relations between graft types and remaining liver volumes and complications (graded using the Clavien 5-tier grading system). The median follow-up was 19 months (range, 10-31 months). During the study period, 553 men and 279 women donated livers, and there were no deaths after living liver donation. The overall, biliary, and major complication (grade ≥ III) rates were 9.3%, 1.7%, and 1.9%, respectively. The graft types and remaining liver volume were associated with significantly different overall, biliary, and major complication rates. Of the 16 patients with major complications, 9 (56.3%) involved biliary complications (2 biliary strictures [12.5%] and 7 bile leakages [43.8%]). Among the 832 donors, the mean aspartate transaminase, alanine aminotransferase, and total bilirubin levels were 23.9 ± 8.1 IU/L, 20.9 ± 11.3 IU/L, and 0.8 ± 0.4 mg/dL, respectively, 6 months after liver donation. In conclusion, biliary complications were the most common types of major morbidity in living liver donors. Donor hepatectomy can be performed successfully with minimal and easily controlled complications. Our study shows that prospective, nationwide cohort data provide an important means of investigating the safety in living liver donation. Liver Transplantation 23 999-1006 2017 AASLD.

Optimal central venous pressure during the neohepatic phase to decrease peak portal vein flow velocity for the prevention of portal hyperperfusion in patients undergoing living donor liver transplantation

BACKGROUND

The association between intraoperative systemic hemodynamic status and preventing portal hyperperfusion, which induces shear stress on the sinusoidal endothelial cells of liver grafts, resulting in poor graft function in live-donor recipients, has not been identified. This study evaluates the effects of systemic hemodynamic parameters (SHPs) during the neohepatic phase on changes in hepatic hemodynamic parameters (HHPs) between the neohepatic phase and the 1st postoperative day.

METHODS

Thirty-eight patients undergoing living donor liver transplantation (LDLT) were enrolled in this study. HHPs (flow velocities of portal vein and hepatic artery) were measured immediately after hepatic artery and bile duct reconstruction and on the first postoperative day. SHPs (mean arterial pressure, central venous pressure [CVP], cardiac index, stroke volume variation, stroke volume index, systemic vascular resistance index, and central venous oxygen saturation) were recorded and averaged for 5 minutes after the measurement of HHPs. The relationships between the SHPs and HHPs were assessed using linear or quadratic regression analysis.

RESULTS

Peak portal vein flow velocity (PVV) decreased on the 1st postoperative day in 24 patients (63%). There was an inverted-U relationship between CVP and the percentage change in PVV (R(2) = 0.241, P = .008). According to the quadratic regression model, the PVV maximally decreased at a CVP of 7.8 mm Hg. No significant correlations were found between the other SHPs and HHPs.

CONCLUSIONS

Maintaining CVP (approximately 8 mm Hg) during the neohepatic phase was clinically beneficial in decreasing PVV to prevent portal hyperperfusion in the early postoperative period of LDLT.

Fourteen successful consecutive cases of ABO-incompatible living donor liver transplantation: new simplified intravenous immunoglobulin protocol without local infusion therapy

Since various innovative strategies including local infusion therapy and rituximab have been introduced, the survivals and outcomes of recipients in ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) have remarkably improved. Thus, ABO-I LDLT can be a feasible therapeutic option for the patient with end-stage liver disease if an ABO-compatible donor is not available. Although most ABO-I protocols are based on rituximab, plasma exchange, and local infusion therapy, treatment strategies have been changing according to a center's preference or their results. Nonetheless, the consensus of the ABO-I LDLT protocol remains undetermined. Herein, we present our experience with new simple ABO-I LDLT protocol and the excellent results for 14 patients from January 2011 to May 2013. All patients were administrated a single dose of rituximab over 7 days before transplantation followed by plasma exchange to lower anti-ABO antibody titer ≤32. The basic immunosuppression protocol consisted of tacrolimus and steroids with mycophenolate mofetil starting 3 days before transplantation. Splenectomy was not performed routinely and local infusion therapy was not applied at the postoperative period. Instead, the patients received intravenous immunoglobulin (IVIG) after LDLT on days 1, 3, and 5. Neither antibody-mediated rejection nor biliary stricture were encountered in the patients, with a mean follow-up of 16.27 ± 9.4 months. This new simplified ABO-I LDLT protocol seems to prevent antibody-mediated rejection and could be considered as the safe and effective modality to overcome the ABO blood-type barrier in LDLT.

Is Systemic heparinization necessary during living donor hepatectomy?

Systemic heparinization has traditionally been performed during living donor hepatectomy (LDH) at most transplant centers because of the possibility of graft vascular thrombosis. However, no consensus on the use of systemic heparinization during LDH has yet emerged. The aims of the present study were to compare donor and recipient outcomes with reference to systemic heparinization and to determine whether or not systemic heparin needs to be administered to living donors. Via a retrospective review, we analyzed the outcomes of 137 LDHs performed at our institution from January 2011 to October 2013; 79 donors received systemic heparinization (group I), whereas 58 did not, but the liver graft was flushed with a heparinized perfusate (group II). Patient demographics, intraoperative parameters, laboratory data, postoperative complications, and survival rates were compared between the 2 groups. The overall complication rates did not differ significantly between the 2 groups, but postoperative bleeding requiring red blood cell transfusions occurred more frequently in group I versus group II (7.6% versus 0.0%, P = 0.03). The incidences of graft vascular thrombosis were similar in the 2 groups, and no graft loss caused by vascular thrombosis was evident during the early postoperative period. Moreover, no difference in either posttransplant graft function or survival was apparent between the 2 groups. The rates of decreases in donor hemoglobin, hematocrit, and platelet count levels during the early postoperative period were significantly higher in group I versus group II. In conclusion, the omission of systemic heparinization during LDH is both feasible and safe, with no adverse effects on donor or recipient outcomes.

Salvage dual graft living donor liver transplantation after major hepatectomy

Salvage living donor liver transplantation (LDLT) after major hepatectomy has been considered a challenging procedure due to operative complexity. We report a successful case of salvage dual graft LDLT after right hepatectomy. A 48-year-old male was transferred to Daegu Catholic University Medical Center because of duodenal variceal bleeding. He underwent right hepatectomy due to hepatocellular carcinoma four years prior. We performed LDLT with dual graft from his wife and sister. During operation, portal vein anastomosis of the right lobe graft was performed using an interposing cadaveric iliac vein graft and the right gastroepiploic artery was anastomosed to the hepatic artery of the left lobe graft. Adequate graft inflow was demonstrated by postoperative imaging studies. He has been doing well with normal graft function for 31 months. Salvage dual graft LDLT could be undertaken successfully in patients with prior major hepatectomy under accurate preoperative planning and proper surgical techniques.

The paracholedochal vein: a feasible option as portal inflow in living donor liver transplantation

Extensive thrombosis of the portal and splenomesenteric veins combined with cavernous transformation of the portal vein (CTPV) has been considered to be a contraindication for living donor liver transplantation (LDLT) due to technical difficulties and perioperative risks. In recent years, several surgical innovations including cavoportal hemitransposition, renoportal anastomosis, and portal arterialization have been introduced to overcome diffuse portal vein thrombosis (PVT) and CTPV, but their outcomes were unsatisfactory with significant morbidity and mortality. Herein, we report two successful cases of adult LDLT in diffuse PVT with CTPV managed using the paracholedochal vein as portal inflow to the graft.

GOAT induced ghrelin acylation regulates hedonic feeding

Ghrelin is an orexigenic hormone that regulates homeostatic and reward-related feeding behavior. Recent evidence indicates that acylation of ghrelin by the gut enzyme ghrelin O-acyl transferase (GOAT) is necessary to render ghrelin maximally active within its target tissues. Here we tested the hypothesis that GOAT activity modulates food motivation and food hedonics using behavioral pharmacology and mutant mice deficient for GOAT and the ghrelin receptor (GHSR). We evaluated operant responding following pharmacological administration of acyl-ghrelin and assessed the necessity of endogenous GOAT activity for operant responding in GOAT and GHSR-null mice. Hedonic-based feeding behavior also was examined in GOAT-KO and GHSR-null mice using a "Dessert Effect" protocol in which the intake of a palatable high fat diet "dessert" was assessed in calorically-sated mice. Pharmacological administration of acyl-ghrelin augmented operant responding; notably, this effect was dependent on intact GHSR signaling. GOAT-KO mice displayed attenuated operant responding and decreased hedonic feeding relative to controls. These behavioral results correlated with decreased expression of the orexin-1 receptor in reward-related brain regions in GOAT-KO mice. In summary, the ability of ghrelin to stimulate food motivation is dependent on intact GHSR signaling and modified by endogenous GOAT activity. Furthermore, GOAT activity is required for hedonic feeding behavior, an effect potentially mediated by forebrain orexin signaling. These data highlight the significance of the GOAT-ghrelin system for the mediation of food motivation and hedonic feeding.

An early single-center experience of portal vein thrombosis in living donor liver transplantation: clinical feature, management and outcome

PURPOSE

Portal vein thrombosis (PVT) has been considered a relative contraindication for living donor liver transplantation (LDLT). However, it is no longer a contraindication of LDLT due to improvement in surgical techniques and approaches to PVT. The aim of this study was to assess the impact of PVT on outcomes in LDLT patients.

METHODS

We retrospectively analyzed the data from 97 adult patients undergoing LDLT in our center from July 2008 to June 2010. Intraoperative findings and preoperative imaging results were reviewed for PVT grading (Yerdel grading). We analyzed the technical aspects and comparisons of risk factors, perioperative variables, and survivals between patients with and without PVT based on the grades.

RESULTS

In the 97 LDLT patients, 18 patients were confirmed to have PVT (18.5%) including grade I cases (n = 8), grade II (n = 7), and grade III (n = 3). Prior treatment of portal hypertension was found to be an independent risk factor for PVT (P = 0.001). The comparisons between PVT and no PVT groups showed no significant difference in intraoperative and postoperative variables except for postoperative bleeding (P = 0.036). The short-term portal vein patency, in-hospital mortality and survival rates were not significantly different between the PVT and control groups.

CONCLUSION

The outcomes are similar to non-PVT group in terms of in-hospital mortality, survival rates, and postoperative complications. Therefore, our study suggests that PVT cannot be considered to be a contraindication for LDLT and LDLT could be undertaken without increased morbidity and mortality in patients with PVT, in spite of operative complexity.

Characteristic clinical and pathologic features for preoperative diagnosed groove pancreatitis

Purpose

Groove pancreatitis is a rare specific form of chronic pancreatitis that extends into the anatomical area between the pancreatic head, the duodenum, and the common bile duct, which are referred to as the groove areas. We present the diagnostic modalities, pathological features and clinical outcomes of a series of symptomatic patients with groove pancreatitis who underwent pancreaticoduodenectomy.

Methods

Six patients undergoing pancreaticoduodenectomy between May 2006 and May 2009 due to a clinical diagnosis of symptomatic groove pancreatitis were retrospectively included in the study.

Results

Five cases were male and one case was female, with a median age at diagnosis of 50 years. Their chief complaints were abdominal pain and vomiting. Abdominal computed tomography, endoscopic ultrasound and endoscopic retrograde cholangiopancreatography were performed. Preoperative diagnosis of all patients was groove pancreatitis. Histological finding was compatible with clinically diagnosed groove pancreatitis in five patients and the pathologic diagnosis of the remaining patient was adenocarcinoma of distal common bile duct. Following pancreaticoduodenectomy, four living patients experienced significant pain alleviation.

Conclusion

The diagnostic imaging modalities of choice for groove pancreatitis are computed tomography and endoscopic ultrasonography. If symptomatic groove pancreatitis is suspected, careful follow-up of patients is necessary and pancreaticoduodenectomy seems to be a reasonable treatment option.

The role of orexin-A in food motivation, reward-based feeding behavior and food-induced neuronal activation in rats

Consumption beyond homeostatic needs, referred to here as reward-based feeding behavior, is a central contributor to the current obesity epidemic worldwide. Importantly, reward-based feeding can be driven by palatability, the taste and texture of the food, as well as cues associated with the consumption of palatable foods. The hypothalamic orexin system regulates both diet preference and anticipation of food rewards making it a likely target to modulate reward-based feeding behavior. In the current manuscript we hypothesized that orexin signaling mediates food-motivated behaviors and reward-based feeding behavior. We further hypothesized that orexin neurons and targets of the orexin system become activated in response to cues associated with the consumption of palatable food. Data from these studies suggest that orexin signaling promotes progressive ratio responding for palatable foods while blockade of orexin signaling attenuates reward-based feeding of a high fat diet. In addition, cues linked to the consumption of chocolate, or the receipt of a daily meal, activate the orexin system and its target regions differentially. Collectively, these data suggest that orexin signaling mediates reward-based feeding behavior and, within specific target regions, may regulate cue-induced overconsumption of palatable foods.

Large bowel obstruction caused by sclerosing peritonitis: contrast-enhanced CT findings

Sclerosing peritonitis (SP) is a rare but serious complication of chronic ambulatory peritoneal dialysis (CAPD). SP is characterized by thickening of the peritoneum that encloses some or all of the small intestine. However, the early clinical features of SP are non-specific and are often not recognized until the patient develops complications. The most common complications of SP appear to be partial or complete small bowel obstruction, small bowel necrosis, and enterocutaneous fistulae, all of which, necessitate surgical intervention and have high mortality rates. Although the CT findings of SP are well recognized, to our knowledge, large bowel obstruction due to SP without peritoneal change have not been reported. We report a case of large bowel obstruction due to peritoneal sclerosis following long-term CAPD.

Magnetic resonance imaging of metaplastic carcinoma of the breast: sonographic and pathologic correlation

Metaplastic carcinoma of the breast is a rare disease. We describe the MRI findings with the correlative sonographic and pathologic features of two cases. On MRI, T2-weighted images demonstrate a relatively well-defined mass with high signal intensity cystic components. Dynamic enhancement subtraction images showed an early enhancing and delayed washout peripheral rim and non-enhancing internal components. A microlobulated, isoechogenic mass with cystic components was seen sonographically, and was histopathology related to necrosis and cystic degeneration. Although these features are not unique, metaplastic carcinoma should be included in the differential diagnosis for breast masses.

Sarcomatoid carcinoma of common bile duct: a case report

Sarcomatoid carcinomas (carcinosarcomas) are rare lesions in the hepatobiliary pancreatic system. We present an extremely rare case of sarcomatoid carcinoma of the common bile duct. The tumor showed a biphasic pattern of intermixed carcinomatous (adenocarcinoma) and sarcomatoid elements (spindle and giant cells). By immunohistochemical staining, cytokeratin and vimentin were demonstrated in the sarcomatoid component. The proliferative activity and the oncoproteins expressed by the tumor were investigated by the PCNA, Ki-67, p53 and Bcl-2 in different tumor fields. Overall, the intensities of PCNA and p53 were moderate in the sarcomatoid component, but mild in the carcinomatous component. However, Ki-67 and Bcl-2 were both negative in the carcinomatous and sarcomatoid components. The possible histogenensis of sarcomatoid carcinoma of the common bile duct is discussed. We report upon an additional extremely rare case of sarcomatoid carcinoma arising in the common bile duct together with its immunohistochemical characteristics, and give details of its proliferative activity and oncoprotein expression.

Renal perfusion abnormality. Coded harmonic angio US with contrast agent

PURPOSE

Coded harmonic angio (CHA) US is a recently developed technique that can depict the effects of contrast agents. The purpose of this study was to determine the role of this technique in depicting the enhancement patterns of various renal perfusion abnormalities compared with dynamic CT.

MATERIAL AND METHODS

During a 6-month period, various renal lesions including renal cell carcinoma (n=12), transitional cell carcinoma (n=5), acute pyelonephritis (n=5), and renal trauma (n=2) were evaluated with CHA US using a microbubble contrast agent. US images were obtained before contrast administration and with a bolus injection of 4 g of microbubble contrast agent (300 mg/ml) every 10 s for 1 min and every minute for 5 min. The contrast enhancement patterns of various renal masses were compared with dynamic CT.

RESULTS

Of 12 renal cell carcinomas, 9 (75%) showed heterogeneous enhancement and the remaining 3 (25%) showed homogeneous enhancement. Enhancement of more than adjacent renal parenchyma was seen 16-252 s after injection. The duration of enhancement was 13-208 s (mean, 80 s). All transitional cell carcinomas showed peripheral enhancement. Enhancement was seen 22-270 s after injection. The duration of enhancement was 191-238 s (mean, 291 s). Five patients with acute pyelonephritis and 2 with renal trauma showed focal perfusion defects not shown on the pre-contrast examinations.

CONCLUSION

CHA US with microbubble contrast agent is an effective US technique for the evaluation of both tumor vascularity and renal perfusion abnormality.

Renal perfusion abnormality. Coded harmonic angio US with contrast agent

PURPOSE

Coded harmonic angio (CHA) US is a recently developed technique that can depict the effects of contrast agents. The purpose of this study was to determine the role of this technique in depicting the enhancement patterns of various renal perfusion abnormalities compared with dynamic CT.

MATERIAL AND METHODS

During a 6-month period, various renal lesions including renal cell carcinoma (n=12), transitional cell carcinoma (n=5), acute pyelonephritis (n=5), and renal trauma (n=2) were evaluated with CHA US using a microbubble contrast agent. US images were obtained before contrast administration and with a bolus injection of 4 g of microbubble contrast agent (300 mg/ml) every 10 s for 1 min and every minute for 5 min. The contrast enhancement patterns of various renal masses were compared with dynamic CT.

RESULTS

Of 12 renal cell carcinomas, 9 (75%) showed heterogeneous enhancement and the remaining 3 (25%) showed homogeneous enhancement. Enhancement of more than adjacent renal parenchyma was seen 16-252 s after injection. The duration of enhancement was 13-208 s (mean, 80 s). All transitional cell carcinomas showed peripheral enhancement. Enhancement was seen 22-270 s after injection. The duration of enhancement was 191-238 s (mean, 291 s). Five patients with acute pyelonephritis and 2 with renal trauma showed focal perfusion defects not shown on the pre-contrast examinations.

CONCLUSION

CHA US with microbubble contrast agent is an effective US technique for the evaluation of both tumor vascularity and renal perfusion abnormality.

Adult-to-adult living donor liver transplantation at the Asan Medical Center, Korea

Between February 1997 and December 2001, 311 adult-to-adult living donor liver transplants (A-A LDLTs) were performed at the Asan Medical Center for patients above 20 years of age. Indications for A-A LDLT were: chronic hepatitis B (203), chronic hepatitis C (5), hepatocellular carcinoma (64), alcoholic cirrhosis (9), cryptogenic cirrhosis (4), secondary biliary cirrhosis (5), primary biliary cirrhosis (1), Wilson' s disease (2), autoimmune hepatitis (1), hepatic tuberculosis (1), cholangiocarcinoma (1), fulminant hepatic failure (14) and primary non-function of cadaveric liver graft (1). Of 311 A-A LDLTs, 36 were of medical high urgency, 20 were for acute and subacute hepatic failure, 15 were for hepato-renal syndrome and 1 was for primary non-function. Recipient age ranged from 27 to 64 years. Donor age ranged from 16 to 62 years. There was no donor mortality. Implanted liver grafts were categorized into seven types: 175 modified right lobe (MRL), 70 left lobe, 32 right lobe, 20 dual grafts, 10 left lobe plus caudate lobe, three extended right lobe and one posterior segment. In MRL, the tributaries of the middle hepatic vein were reconstructed by interpositioning a vein graft. Indication for dual graft implantation was the same as single graft A-A LDLT, and four of 20 were emergency cases. Of 20 dual grafts, 14 received two left lobes, four received a left lobe and a lateral segment, one received a right lobe and a left lobe and one received a lateral segment and a posterior segment. Graft volume ranged from 28% to 83% of the standard liver volume of the recipients. There were 33 (10.6%) in-hospital mortalities (< 4 months) among the 310 patients after 311 A-A LDLTs. Of the 36 patients receiving emergency transplants, 31 survived. These encouraging results justify the expansion of A-A LDLT in coping with increasing demands, even in urgent situations. We have aimed to introduce the establishment of the efficacy of A-A LDLT in various end-stage chronic and acute liver diseases, as well as new technical advances to overcome small graft-size syndrome by using dual-graft implantation and MRL, both of which were first developed in our department.

A case of bronchiolitis obliterans organizing pneumonia associated with adenovirus

A 58-year-old man described a short history of dyspnea and a preceding flu like illness with roentgenographic features of an interstitial lung disease. An open lung biopsy specimen from him showed bronchiolitis obliterans with organizing pneumonia (BOOP). Adenovirus was isolated from a throat swab. There was both clinical and radiographic improvement with supportive care. We herein report a first case of BOOP associated with adenovirus in Korea.