Surgical outcome and risk scoring to predict survival after hepatic resection for hepatocellular carcinoma with portal vein tumor thrombosis

Backgrounds/Aims

The hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is classified as the advanced stage (BCLC stage C) with extremely poor prognosis, and in current guidelines is recommended for systemic therapy. This study aimed to evaluate the surgical outcomes and long-term prognosis after hepatic resection (HR) for patients who have HCC combined with PVTT.

Methods

We retrospectively analyzed 332 patients who underwent HR for HCC with PVTT at ten tertiary referral hospitals in South Korea.

Results

The median overall and recurrence-free survival after HR were 32.4 and 8.6 months, while the 1-, 3-, and 5-year overall survival rates were 75%, 48%, and 39%, respectively. In multivariate analysis, tumor number, tumor size, AFP, PIVKA-II, neutrophil-to-lymphocyte ratio, and albumin-bilirubin (ALBI) grade were significant prognostic factors. The risk scoring was developed using these seven factors-tumor, inflammation and hepatic function (TIF), to predict patient prognosis. The prognosis of the patients was well stratified according to the scores (log-rank test, p < 0.001).

Conclusions

HR for patients who have HCC combined with PVTT provided favorable survival outcomes. The risk scoring was useful in predicting prognosis, and determining the appropriate treatment strategy for those patients who have HCC with PVTT.

Left lobe living donor liver transplantation using the resection and partial liver segment 2-3 transplantation with delayed total hepatectomy (RAPID) procedure in cirrhotic patients: First case report in Korea

In liver transplantation, the primary concern is to ensure an adequate future liver remnant (FLR) volume for the donor, while selecting a graft of sufficient size for the recipient. The living donor-resection and partial liver segment 2-3 transplantation with delayed total hepatectomy (LD-RAPID) procedure offers a potential solution to expand the donor pool for living donor liver transplantation (LDLT). We report the first case involving a cirrhotic patient with autoimmune hepatitis and hepatocellular carcinoma, who underwent left lobe LDLT using the LD-RAPID procedure. The living liver donor (LLD) underwent a laparoscopic left hepatectomy, including middle hepatic vein. The resection on the recipient side was an extended left hepatectomy, including the middle hepatic vein orifice and caudate lobe. At postoperative day 7, a computed tomography scan showed hypertrophy of the left graft from 320 g to 465 mL (i.e., a 45.3% increase in graft volume body weight ratio from 0.60% to 0.77%). After a 7-day interval, the diseased right lobe was removed in the second stage surgery. The LD-RAPID procedure using left lobe graft allows for the use of a small liver graft or small FLR volume in LLD in LDLT, which expands the donor pool to minimize the risk to LLD by enabling the donation of a smaller liver portion.

3D auto-segmentation of biliary structure of living liver donors using magnetic resonance cholangiopancreatography for enhanced preoperative planning

BACKGROUND

This study aimed to develop an automated segmentation system for biliary structures using a deep learning model, based on data from magnetic resonance cholangiopancreatography (MRCP).

MATERIALS AND METHODS

Living liver donors who underwent MRCP using the gradient and spin echo technique followed by three-dimensional modeling were eligible for this study. A three-dimensional residual U-Net model was implemented for the deep learning process. Data were divided into training and test sets at a 9:1 ratio. Performance was assessed using the dice similarity coefficient to compare the model's segmentation with the manually labeled ground truth.

RESULTS

The study incorporated 250 cases. There was no difference in the baseline characteristics between the train set (n=225) and test set (n=25). The overall mean Dice Similarity Coefficient was 0.80±0.20 between the ground truth and inference result. The qualitative assessment of the model showed relatively high accuracy especially for the common bile duct (88%), common hepatic duct (92%), hilum (96%), right hepatic duct (100%), and left hepatic duct (96%), while the third-order branch of the right hepatic duct (18.2%) showed low accuracy.

CONCLUSION

The developed automated segmentation model for biliary structures, utilizing MRCP data and deep learning techniques, demonstrated robust performance and holds potential for further advancements in automation.

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

BACKGROUND

Recently, the outcomes of surgical treatment for advanced hepatocellular carcinoma (HCC) have improved. However, despite the technical advancements in laparoscopic liver resection (LLR), it is still not recommended as the standard treatment for HCC with portal vein tumor thrombosis (PVTT) because of the poor oncological outcomes. This study aims to compare the clinical outcomes of open liver resection (OLR) and LLR in patients with HCC with PVTT.

METHODS

A total of 86 patients with PVTT confirmed in the pathological report between January 2014 and December 2018, were enrolled. Short-term, postoperative, and long-term outcomes, including recurrence-free survival and overall survival rates, were evaluated.

RESULTS

No difference between the two groups, except for age, was detected. The median age in the laparoscopic group was significantly higher than that in the open group. Regarding the pathological features, the maximal tumor size was significantly larger in the OLR; other pathological factors did not differ. There was no significant difference between overall survival (OS) and recurrence-free survival (RFS). Vp3 PVTT (hazards ratio [HR] 6.1, 95% confidence interval [CI] 1.9-18.5), Edmondson grade IV (HR 4.7, 95% CI 1.7-12.9, p = 0.003), and intrahepatic metastasis (HR 3.9, 95% CI 2.1-7.2, p < 0.001) remained the unique independent predictors of recurrence-free survival according to a multivariate Cox proportional hazard regression analysis.

CONCLUSIONS

Laparoscopic liver resection for the management of HCC with PVTT provides the same short- and long-term results as those of the open approach.

Laparoscopic liver resection as a treatment option for intrahepatic cholangiocarcinoma

Laparoscopic liver resection (LLR) remains controversial in the treatment of intrahepatic cholangiocarcinoma (ICC). The aim of the present study is to investigate the outcomes of LLR for ICC compared to open liver resection (OLR). We retrospectively reviewed patients who underwent surgery for ICC between January 2013 and February 2020. OLR and LLR were compared after propensity score matching (PSM). Overall survival (OS) and recurrence-free survival (RFS) were compared between the matched groups. During the study period, 219 patients met the inclusion criteria (OLR = 170 patients, 77.6%; LLR = 49 patients, 22.4%). Two groups of 43 patients each were analyzed after PSM. The 5-year RFS and OS were 44.6% and 47.9% in the OLR group and 50.9% and 39.8% in the LLR group, respectively. Hospital stay and intensive care unit care were significantly shorter and lower in the LLR group than in the OLR group, respectively. Total postoperative complications and complication rates for those Clavien-Dindo grade 3 or higher were similar between the OLR group and the LLR group. Multiple tumors and lymph node metastases were predisposing factors for tumor recurrence and death in multivariate analysis. The present study suggests that LLR should be considered in selective ICC because of short hospitalization and similar oncologic outcome and overall survival.

Liver resection in selective hepatocellular carcinoma with Vp3 or Vp4 portal vein tumor thrombosis improves prognosis

BACKGROUND/AIM

Hepatocellular carcinoma (HCC) tumor thrombi located in the first branch of the portal vein (Vp3) or in the main portal trunk (Vp4) are associated with poor prognosis. This study aimed to investigate the clinicopathological characteristics and risk factors for HCC recurrence and mortality following liver resection (LR) in patients with Vp3 or Vp4 HCC.

METHODS

The study included 64 patients who underwent LR for HCC with Vp3 or Vp4 portal vein tumor thrombosis (PVTT).

RESULTS

Fifty-eight patients (90.6%) had Vp3 PVTT, whereas the remaining six patients exhibited Vp4 PVTT. The median tumor size measured 8 cm, with approximately 36% of patients presented with multiple tumors. Fifty-four patients (84.4%) underwent open LR, whereas 10 patients underwent laparoscopic LR. In the Vp4 cases, combined LR and tumor thrombectomy were performed. The 3-year cumulative disease-free survival rate was 42.8% for the Vp3 group and 22.2% for the Vp4 group. The overall survival (OS) rate at 3 years was 47.9% for the Vp3 group and 60.0% for the Vp4 group. Intrahepatic metastasis has been identified as an important contributor to HCC recurrence. High hemoglobin levels are associated with high mortality.

CONCLUSION

LR is a safe and effective treatment modality for selected patients with Vp3 or Vp4 HCC PVTT. This suggests that LR is a viable option for these patients, with favorable outcomes in terms of OS.

Preoperative assessment of microvascular invasion risk using gadoxetate-enhanced MRI for predicting outcomes after liver transplantation for single hepatocellular carcinoma within the Milan criteria

OBJECTIVE

To compare therapeutic outcomes after liver transplantation (LT) between hepatocellular carcinomas (HCC) with low and high risk for microvascular invasion (MVI) within the Milan criteria evaluated preoperatively.

METHODS

Eighty patients with a single HCC who underwent LT as the initial therapy between 2008 and 2017 were included from two tertiary referral medical centers in a HBV-predominant population. A preoperative MVI-risk model was used to identify low- and high-risk patients. Recurrence-free survival (RFS) after LT between the two risk groups was compared using Kaplan-Meier curves with the log-rank test. Prognostic factors for RFS were identified using a multivariable Cox hazard regression analysis.

RESULTS

Eighty patients were included (mean age, 51.8 years +/- 7.5 [standard deviation], 65 men). Patients were divided into low-risk (n = 64) and high-risk (n = 16) groups for MVI. The RFS rates after LT were significantly lower in the MVI high-risk group compared to the low-risk group at 1 year (75.0% [95% CI: 56.5-99.5%] vs. 96.9% [92.7-100%], p = 0.048), 3 years (62.5% [42.8-91.4%] vs. 95.3% [90.3-100%], p = 0.008), and 5 years (62.5% [42.8-91.4%] vs. and 95.3% [90.3-100%], p = 0.008). In addition, multivariable analysis showed that MVI high risk was the only significant factor for poor RFS (p = 0.016).

CONCLUSION

HCC patients with a high risk of MVI showed significantly lower RFS after LT than those without. This model could aid in selecting optimal candidates in addition to the Milan criteria when considering upfront LT for patients with HCC if alternative treatment options are available.

CLINICAL RELEVANCE STATEMENT

High risk for microvascular invasion (MVI) in hepatocellular carcinoma patients lowered recurrence-free survival after liver transplantation, despite meeting the Milan criteria. Identifying MVI risk could aid candidate selection for upfront liver transplantation, particularly if alternative treatments are available.

KEY POINTS

• A predictive model-derived microvascular invasion (MVI) high- and low-risk groups had a significant difference in the incidence of MVI on pathology. • Recurrence-free survival after liver transplantation (LT) for single hepatocellular carcinoma (HCC) within the Milan criteria was significantly different between the MVI high- and low-risk groups. • The peak incidence of tumor recurrence was 20 months after liver transplantation, probably indicating that HCC with high risk for MVI had a high risk of early (≤ 2 years) tumor recurrence.

Recurrence-free Survival After Liver Transplantation Versus Surgical Resection for Hepatocellular Carcinoma: Role of High-risk MRI Features

BACKGROUND

This study aimed to evaluate recurrence-free survival (RFS) and overall survival (OS) after liver transplantation (LT) or liver resection (LR) for hepatocellular carcinoma (HCC) and perform subgroup analysis for HCC with high-risk imaging findings for recurrence on preoperative liver magnetic resonance imaging (MRI; high-risk MRI features).

METHODS

We included patients with HCC eligible for both LT and LR and received either of the treatments between June 2008 and February 2021 from 2 tertiary referral medical centers after propensity score-matching. RFS and OS were compared between LT and LR using Kaplan-Meier curves with the log-rank test.

RESULTS

Propensity score-matching yielded 79 patients in the LT group and 142 patients in the LR group. High-risk MRI features were noted in 39 patients (49.4%) in the LT group and 98 (69.0%) in the LR group. The Kaplan-Meier curves for RFS and OS were not significantly different between the 2 treatments among the high-risk group (RFS, P  = 0.079; OS, P  = 0.755). Multivariable analysis showed that treatment type was not a prognostic factor for RFS and OS ( P  = 0.074 and 0.937, respectively).

CONCLUSIONS

The advantage of LT over LR for RFS may be less evident among patients with high-risk MRI features.

Factors associated with operational tolerance after liver transplantation: a single center retrospective study

Background

Liver transplantation has adverse effects from life-long immunosuppression that limit the improvement of long-term outcomes. Achieving clinical operational tolerance is a major goal in organ transplantation.

Methods

This study analyzed liver transplantation patients at a single institution from 1998 to 2020, excluding those who died within 1-year posttransplant. Operational tolerance was defined as normal liver function even after immunosuppressive drugs were discontinued. Propensity score matching was implemented at a 1:2 ratio for the tolerant group (TG) and the nontolerant group (NTG).

Results

Out of 2,300 recipients, 99 achieved operational tolerance without rejection. No significant differences in sex or body mass index (BMI) were found between the TG and NTG. There was a significantly higher percentage of children in the TG (24.0%) than in the NTG (10.1%). The NTG had more living donor liver transplants. Among 2,054 adult recipients, no significant differences in age, sex, or BMI were found between the TG and the NTG. However, the rate of living donor liver transplantation was 40.3% (29/75) in the TG and 84.8% in the NTG (P<0.001). The propensity score-matched analysis showed higher chronic renal failure rates and a higher graft recipient weight ratio in the TG, along with shorter warm ischemic times during surgery. After immunosuppressant withdrawal, a significant increase in the ratio of CD4+CD25+ T cells to total CD4+ T cells was observed in the TG.

Conclusions

These findings suggest that larger, healthier grafts are more conducive to inducing tolerance, and regulatory T cells are crucial in achieving tolerance.

Benefit of living donor liver transplantation in graft survival for extremely high model for end-stage liver disease score ≥35

BACKGROUND AND AIMS

Living liver donation with high model for end-stage liver disease (MELD) score was discouraged despite organ shortage. This study aimed to compare graft survival between living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT) recipients with extremely high-MELD (score of ≥35).

METHODS

Between 2008 and 2018, 359 patients who underwent liver transplantation with a MELD score ≥35 were enrolled. We compared graft survival between LDLT and DDLT after propensity score matching (PSM) and performed subgroup analysis according to donor type.

RESULTS

After PSM, there was no statistical difference in graft survival between the LDLT and DDLT groups (p = .466). Old age, acute on chronic liver failure, re-transplantation, preoperative intensive care unit stay and red blood cell (RBC) transfusion during the operation were risk factors for graft failure (p = .046, .005, .032, .015 and .001, respectively). Biliary complications were more common in the LDLT group (p = .021), while viral infection, postoperative uncontrolled ascites, and postoperative hemodialysis were more common in the DDLT group (p = .002, .018, and .027, respectively). In the LDLT group, acute chronic liver failure, intraoperative RBC transfusion, and early postoperative complications were risk factors for graft failure (p = .007, <.001, and .001, respectively).

CONCLUSION

Our study showed that LDLT is not inferior to DDLT in graft survival if appropriate risk evaluation is performed in cases of extremely high-MELD scores. This result will help overcome organ shortages in high-MELD liver transplantation.

Donor Safety and Risk Factors of Pure Laparoscopic Living Donor Right Hepatectomy: A Korean Multicenter Study

OBJECTIVE

The aim of this study was to identify safety and risk factors of living donor after pure laparoscopic donor right hepatectomy in a Korean multicenter cohort study.

BACKGROUND

Pure laparoscopic donor right hepatectomy is not yet a standardized surgical procedure due to lack of data.

METHODS

This retrospective study included 543 patients undergoing PLRDH between 2010 and 2018 in 5 Korean transplantation centers. Complication rates were assessed and multivariate logistic regression analyses were performed to identify risk factors of open conversion, overall complications, major complications, and biliary complications.

RESULTS

Regarding open conversion, the incidence was 1.7% and the risk factor was body mass index >30 kg/m 2 [ P =0.001, odds ratio (OR)=22.72, 95% CI=3.56-146.39]. Rates of overall, major (Clavien-Dindo classification III-IV), and biliary complications were 9.2%, 4.4%, and 3.5%, respectively. For overall complications, risk factors were graft weight >700 g ( P =0.007, OR=2.66, 95% CI=1.31-5.41), estimated blood loss ( P <0.001, OR=4.84, 95% CI=2.50-9.38), and operation time >400 minutes ( P =0.01, OR=2.46, 95% CI=1.25-4.88). For major complications, risk factors were graft weight >700 g ( P =0.002, OR=4.01, 95% CI=1.67-9.62) and operation time >400 minutes ( P =0.003, OR=3.84, 95% CI=1.60-9.21). For biliary complications, risk factors were graft weight >700 g ( P =0.01, OR=4.34, 95% CI=1.40-13.45) and operation time >400 minutes ( P =0.01, OR=4.16, 95% CI=1.34-12.88).

CONCLUSION

Careful donor selection for PLRDH considering body mass index, graft weight, estimated blood loss, and operation time combined with skilled procedure can improve donor safety.

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

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

Automated 3D liver segmentation from hepatobiliary phase MRI for enhanced preoperative planning

Recent advancements in deep learning have facilitated significant progress in medical image analysis. However, there is lack of studies specifically addressing the needs of surgeons in terms of practicality and precision for surgical planning. Accurate understanding of anatomical structures, such as the liver and its intrahepatic structures, is crucial for preoperative planning from a surgeon's standpoint. This study proposes a deep learning model for automatic segmentation of liver parenchyma, vascular and biliary structures, and tumor mass in hepatobiliary phase liver MRI to improve preoperative planning and enhance patient outcomes. A total of 120 adult patients who underwent liver resection due to hepatic mass and had preoperative gadoxetic acid-enhanced MRI were included in the study. A 3D residual U-Net model was developed for automatic segmentation of liver parenchyma, tumor mass, hepatic vein (HV), portal vein (PV), and bile duct (BD). The model's performance was assessed using Dice similarity coefficient (DSC) by comparing the results with manually delineated structures. The model achieved high accuracy in segmenting liver parenchyma (DSC 0.92 ± 0.03), tumor mass (DSC 0.77 ± 0.21), hepatic vein (DSC 0.70 ± 0.05), portal vein (DSC 0.61 ± 0.03), and bile duct (DSC 0.58 ± 0.15). The study demonstrated the potential of the 3D residual U-Net model to provide a comprehensive understanding of liver anatomy and tumors for preoperative planning, potentially leading to improved surgical outcomes and increased patient safety.

Upper thigh skeletal muscle index predicts outcomes in liver transplant recipients

Purpose

The skeletal muscle index (SMI) at the L3 level is widely used to diagnose sarcopenia. The upper thigh (UT) also reflects changes in whole-body muscle mass, but no study has examined this using the UT to diagnose sarcopenia in liver transplantation (LT). This study aimed to determine an optimal cut-off value for UT-SMI and investigate how sarcopenia diagnosed by UT-SMI correlates with outcomes in LT recipients.

Methods

In this retrospective study of 332 LT patients from 2018 to 2020, we investigated the association between sarcopenia diagnosed by UT-SMI and patient outcomes after LT.

Results

The cut-off values for UT-SMI were 38.3 cm2/m2 for females (area under the curve [AUC], 0.927; P < 0.001) and 46.7 cm2/m2 for males (AUC, 0.898; P < 0.001). The prevalence of sarcopenia diagnosed by UT-SMI was 33.4% in our cohort. Patient and graft survival rates in the UT-SMI sarcopenia group were significantly poorer than those in the UT-SMI non-sarcopenia group (P < 0.001 and P < 0.001). UT-SMI was an independent prognostic factor for patient survival (hazard ratio [HR], 2.182; 95% confidence interval [CI], 1.183-4.025; P = 0.012) and graft survival (HR, 2.227; 95% CI, 1.054-4704; P = 0.036) in our multivariable Cox analysis.

Conclusion

We confirmed that sarcopenia diagnosed by UT-SMI is associated with outcomes in LT recipients. In addition, UT-SMI was identified as an independent prognostic factor for patient survival and graft survival. Therefore, UT-SMI could be a good option for CT-based evaluations of sarcopenia in LT recipients.

Safety and Efficacy of Conversion to Once-Daily Tacrolimus from Twice-Daily Tacrolimus in Pediatric Liver Transplant Recipients

BACKGROUND

Nonadherence to immunosuppression is the most common cause of late acute rejection in pediatric liver transplant (LT) recipients. A prolonged-release once-daily tacrolimus formulation was developed to improve adherence and long-term allograft survival.

METHODS

We screened 179 pediatric LT recipients who converted from twice-daily tacrolimus (TD-TAC) to once-daily tacrolimus (OD-TAC) between February 2011 and September 2019.

RESULTS

One hundred seventy-nine recipients converted to OD-TAC and were followed for 18 months. 152 OD-TAC-converted recipients (84.9%) experienced uneventful follow-up, while 21 recipients showed LFT elevation. Four recipients had biopsy-proven acute rejection within six months of conversion, all of which were successfully treated with steroid pulse. 166 recipients (92.7%) remain on OD-TAC and 13 (7.3%) were switched back to TD-TAC. The mean tacrolimus trough level significantly decreased three months following conversion (3.14 ± 1.9 ng/mL) compared with pre-conversion levels (3.69 ± 1.98 ng/mL). Mean tacrolimus trough levels remained unchanged from 3 months to 12 months following conversion. Percent coefficient of variation of tacrolimus trough levels decreased significantly from 32.5 ± 16.4 ng/mL to 27.5 ± 15.6 ng/mL after conversion to OD-TAC, reflecting a decrease in variation of tacrolimus trough levels following conversion.

CONCLUSIONS

Conversion to OD-TAC in pediatric LT recipients with stable graft function is safe and effective.

LEVEL OF EVIDENCE

Level IV.

Ventilator support in the pretransplant period predisposes early graft failure after deceased donor liver transplantation

Purpose

Deceased donor liver transplantation (DDLT) recipients in Korea are generally sicker due to an increasing organ shortage. In the present study, the risk factors for early 30-day liver graft failure after DDLT were identified.

Methods

From August 2017 to February 2021, 265 adult DDLTs were performed. The characteristics of patients with and without 30-day graft failure were compared.

Results

Liver graft failure occurred in 11 patients (17.7%) after DDLT. Baseline and perioperative characteristics of donors and recipients were not statistically significantly different between the 2 groups. The cumulative graft and overall survival rates at 6 months were 83.9% and 88.7%, respectively. Multivariate analysis showed ventilator support in the pretransplant period was a predisposing factor for 30-day graft failure after DDLT.

Conclusion

Present study indicates that cautious decision is required when allocating DDLT in critically ill patients on mechanical ventilatory support.

Long-Term Outcomes of Liver Transplantation in Hepatocellular Carcinoma with Bile Duct Tumor Thrombus: A Comparison with Portal Vein Tumor Thrombus

Liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) remains controversial. This study analyzed the recurrence and overall survival rates through long-term results after LT in HCC patients with BDTT and compared the results after LT in HCC patients with portal vein tumor thrombus (PVTT). We performed a retrospective study of 45 patients with PVTT, 16 patients with BDTT, and 11 patients with coexisting PVTT and BDTT among HCC patients who underwent LT at a single center from 1999 to 2020. The HCC recurrence rates were 40.4% at 1 year, 30.3.3% at 2 years, and 27.6% at 3 years in the PVTT group; 66.7%, 53.3%, and 46.7% in the BDTT group; and 22.2%, 22.2%, and 0% in the coexisting group (p = 0.183). Overall patient survival rates were 68.4% at 1 year, 54.3% at 2 years, and 41.7% at 3 years in the PVTT group; 81.3%, 62.5%, and 48.2% in the BDTT group; and 63.6%, 27.3%, and 0% in the coexisting group (p = 0.157). In the multivariate analysis, the pre-transplantation model for tumor recurrence after liver transplantation (MoRAL) score and model for end-stage liver disease (MELD) score were found to be independent risk factors for recurrence and survival in all groups. HCC patients with BDTT showed no difference in recurrence and survival compared with HCC patients with PVTT at the long-term follow-up after LT.

Graft-recipient-weight ratio and lowered immunosuppression is important for the success of adult liver retransplantation

This study analyzed the risk of liver retransplantation and factors related to better outcome. Adult liver transplantations performed during 1996-2021 were included. Comparison between first transplantation and retransplantation were performed. Among retransplantation cases, comparison between whole liver and partial liver graft was performed. Multivariable Cox analyses for analyzing risk factors for primary graft and overall patient survival were performed for the entire cohort as well as the subgroup of patients with retransplantation. A total 2237 transplantations from 2135 adults were included and 103 cases were retransplantation. A total of 44 cases (42.7%) were related to acute graft dysfunction while 59 cases (57.3%) were related to subacute or chronic graft dysfunction. Retransplantation was related poor primary graft (HR 3.439, CI 2.230-5.304, P < 0.001) and overall patient survival. (HR 2.905, CI 2.089-4.040, P < 0.001) Among retransplantations, mean serum FK506 trough level ≥ 9 ng/mL was related to poor primary graft (HR 3.692, CI 1.288-10.587, P = 0.015) and overall patient survival. (HR 2.935, CI 1.195-7.211, P = 0.019) Graft-recipient-weight ratio under 1.0% was related to poor overall patient survival in retransplantations. (HR 3.668, CI 1.150-11.698, P = 0.028). Retransplantation can be complicated with poor graft and patient survival compared to first transplantation, especially when the graft size is relatively small. Lowering the FK506 trough level during the first month can be beneficial for outcome.

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

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

Comparison of two doses of intrathecal morphine in laparoscopic donor hepatectomy: A randomized double-blinded non-inferiority trial

BACKGROUND

Intrathecal morphine (ITM) injection is an effective postoperative analgesic strategy in open or laparoscopic donor hepatectomy; however, the optimal dose has not been determined. In this trial, we compared the post-operative analgesic effects of two doses (300 vs. 400 μg) of ITM injections.

METHODS

In this prospective randomized non-inferiority trial, 56 donors were divided into either the 300 μg or 400 μg ITM group (n = 28, each). The primary outcome was the resting pain score at 24 h postoperatively. Pain scores, cumulative opioid consumption, and side effects (postoperative nausea and vomiting [PONV]) were compared up to 48 h postoperatively.

RESULTS

Fifty-five donors participated in the entire study. The mean resting pain scores at 24 h after surgery were 1.7 ± 1.6 and 1.7 ± 1.1 in the ITM 300 and ITM 400 groups, respectively (mean difference, 0 [95% CI, -.8 to .7], p = .978). The upper limit of the 95% CI was lower than the prespecified non-inferiority margin (δ = 1), indicating that non-inferiority had been established. The incidence of PONV was lower in the ITM 300 group than in the ITM 400 group at 18 (p = .035) and 24 h postoperatively (p = .015). There were no significant differences in the resting and coughing pain scores and cumulative opioid consumption at any time point.

CONCLUSION

For laparoscopic donor hepatectomy, preoperative ITM 300 μg exhibited non-inferior postoperative analgesic effects compared to ITM 400 μg, with a lower incidence of PONV.

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

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

Risk Factors Associated With Surgical Morbidities of Laparoscopic Living Liver Donors

OBJECTIVE

This study analyzed the incidence and risk factors for surgical morbidities of laparoscopic living donors.

BACKGROUND

Although laparoscopic living donor programs have been established safely in leading centers, donor morbidities have not been discussed sufficiently.

METHODS

Laparoscopic living donors operated on from May 2013 to June 2022 were reviewed. Donor complications were reviewed, and factors related to bile leakage and biliary stricture were analyzed using the multivariable logistic regression method.

RESULTS

A total of 636 donors underwent laparoscopic living donor hepatectomy. The open conversion rate was 1.6%, and the 30-day complication rate was 16.8% (n=107). Grade IIIa and IIIb complications occurred in 4.4% (n=28) and 1.9% (n=12) of patients, respectively. The most common complication was bleeding (n=38, 6.0%). Fourteen donors (2.2%) required reoperation. Portal vein stricture, bile leakage, and biliary stricture occurred in 0.6% (n=4), 3.3% (n=21), and 1.6% (n=10) of cases, respectively. The readmission rate and reoperation rate were 5.2% (n=33) and 2.2% (n=14), respectively. Risk factors related to bile leakage were 2 hepatic arteries in the liver graft (OR=13.836, CI=4.092-46.789, P <0.001), division-free margin<5 mm from the main duct (OR=2.624, CI=1.030-6.686, P =0.043), and estimated blood loss during operation (OR=1.002, CI=1.001-1.003, P =0.008), while the Pringle maneuver (OR=0.300, CI=0.110-0.817, P =0.018) was protective against leakage. Regarding biliary stricture, bile leakage was the only significant factor (OR=11.902, CI=2.773-51.083, P =0.001).

CONCLUSIONS

Laparoscopic living donor surgery showed excellent safety for the majority of donors, and critical complications were resolved with proper management. To minimize bile leakage, cautious surgical manipulation is needed for donors with complex hilar anatomy.

Physical Performance Decline During the Early Posttransplantation Period Affects Survival After Living Donor Liver Transplantation

BACKGROUND

Patient physical performance has been emphasized in liver transplant recipients; however, evidence for living donor liver transplantation (LDLT) patients is lacking. This study investigated the impact of physical performance decline during the early posttransplantation period on survival and risk factors for this decline in LDLT recipients.

METHODS

From national registry data, 2703 LDLT patients were divided into 2 groups based on the change in their Karnofsky performance status (KPS) between 1 and 6 mo posttransplantation: declined KPS (n = 188) and control (n = 2515). Multivariable analyses were conducted to control for confounders, including posttransplantation complications.

RESULTS

Estimated 5-y patient survival rates were 91.6% in the declined KPS group and 96.3% in the control group, favoring the latter ( P = 0.003). The survival hazard of KPS decline was significant in a baseline covariates-adjusted Cox model (hazard ratio [HR], 2.60; 95% confidence interval [CI], 1.37-4.95) and an adjusted model accounting for posttransplantation complications (HR, 3.38; 95% CI, 1.70-6.72). In subgroup analyses, KPS decline independently reduced survival in patients without complications (HR, 3.95; 95% CI, 1.67-9.34), and the trend was similar in patients with complications, although significance was marginal (HR, 3.02; 95% CI, 0.98-9.27). We found that only posttransplantation complications, such as rejection, infection, bile duct complication, and vascular complication, were significant risk factors for KPS decline after LDLT.

CONCLUSIONS

Physical performance decline during the early posttransplantation period independently reduced survival rates, and posttransplantation complications were the only significant risk factors for physical performance decline in LDLT recipients.

Days alive and out of hospital and graft survival after living donor liver transplantation

Background

Days alive and out of hospital (DAOH) is a simple metric representing the number of days not in hospital within a defined postoperative period. In a case of mortality within the defined period, the DAOH is considered zero. DAOH has been validated in various surgical procedures, but not in living donor liver transplantation (LDLT). This study aimed to demonstrate correlation between DAOH and graft failure after LDLT.

Methods

In this cohort study, we identified 1,335 adult-to-adult LDLT performed from June 1997 to April 2019 in our institution. We calculated DAOH at 30, 60, and 90 days among survivors and divided the recipients according to the estimated threshold of each defined period.

Results

The median duration of hospital stay after LDLT in the entire population was 25 (interquartile 22-41) days. Mean DAOH of survivors at 30, 60, and 90 days were 3.3 (±3.9), 19.7 (±15.9), and 40.3 (±26.3) days, respectively. We estimated the thresholds associated with three-year graft failure for DAOH at 30, 60, and 90 days and they were 1, 12, and 42 days, respectively. The incidence of graft failure was higher in recipients with short DAOH than long DAOH (10.9% vs. 23.6%, 10.3% vs. 24.3%, and 9.3% vs. 22.2% for DAOH at 30, 60, and 90 days, respectively). Among survivors at 60 days, recipients with short DAOH showed significantly higher incidence of three-year graft failure [hazard ratio (HR), 2.49; 95% confidence interval (CI): 1.86-3.34; P<0.001].

Conclusions

Considering clinical situations after LDLT, DAOH at 60 days may be a valid outcome measure.

Hepatic venous territory mapping in living donor liver transplantation using right liver graft: an objective parameter for venous reconstruction

Purpose

This study evaluated the clinical implication of hepatic venous territory mapping in living donor liver transplantation.

Methods

Living donor liver transplantations performed using right graft since 2017 were included. Hepatic venous volume mapping was started in 2019. Risk factors for graft failure and overall survival were analyzed. Analysis for factors related to occlusion of reconstructed vein was performed.

Results

Among 445 patients included, 213 underwent hepatic venous mapping. Hepatic venous mapping itself was not a significant factor for graft (hazard ratio [HR], 0.958; 95% confidence interval [CI], 0.441-2.082; P = 0.913) and overall survival (HR, 0.627; 95% CI, 0.315-1.247; P = 0.183). Inferior hepatic vein occlusion was a significant risk factor for both graft survival (HR, 8.795; 95% CI, 1.628-47.523; P = 0.012) and overall survival (HR, 11.13; 95% CI, 2.460-50.300; P = 0.002). In a subgroup with middle hepatic vein reconstruction, occlusion was a significant risk factor for overall survival (HR, 3.289; 95% CI, 1.304-8.296; P = 0.012). In patients with middle hepatic vein reconstruction whose venous territory volumes were measured, right anterior volume of ≥300 cm³ was protective for vein occlusion (OR, 0.317; 95% CI, 0.152-0.662; P = 0.002). In patients with V5 reconstruction, V5 volume of ≥150 cm³ was protective for vein occlusion (OR, 0.253; 95% CI, 0.087-0.734; P = 0.011).

Conclusion

Inferior and middle hepatic vein reconstruction has significant impact on clinical outcome. Hepatic venous territory mapping can provide an objective measure for successful reconstruction of venous branches.

Comparison of postoperative analgesic effects of erector spinae plane block and quadratus lumborum block in laparoscopic liver resection: study protocol for a randomized controlled trial

BACKGROUND

Compared with open surgery, laparoscopic liver resection is a minimally invasive surgical technique. However, a number of patients experience moderate-to-severe postoperative pain after laparoscopic liver resection. This study aims to compare the postoperative analgesic effects of erector spinae plane block (ESPB) and quadratus lumborum block (QLB) in patients undergoing laparoscopic liver resection.

METHODS

One hundred and fourteen patients undergoing laparoscopic liver resection will be randomly allocated to three groups (control, ESPB, or QLB) in a 1:1:1 ratio. In the control group, participants will receive systemic analgesia consisting of regular NSAIDs and fentanyl-based patient-controlled analgesia (PCA) according to the institutional postoperative analgesia protocol. In the two experimental groups (ESPB or QLB group), the participants will receive preoperative bilateral ESPB or bilateral QLB in addition to systemic analgesia according to the institutional protocol. ESPB will be performed at the 8th thoracic vertebra level with ultrasound guidance before surgery. QLB will be performed in the supine position on the posterior plane of the quadratus lumborum with ultrasound guidance before surgery. The primary outcome is cumulative opioid consumption 24 h after surgery. Secondary outcomes are cumulative opioid consumption, pain severity, opioid-related adverse events, and block-related adverse events at predetermined time points (24, 48, and 72 h after surgery). Differences in plasma ropivacaine concentrations in the ESPB and QLB groups would be investigated, and the quality of postoperative recovery among the groups will be compared.

DISCUSSION

This study will reveal the usefulness of ESPB and QLB in terms of postoperative analgesic efficacy and safety in patients undergoing laparoscopic liver resection. Additionally, the study results will provide information on the analgesic superiority of ESPB versus QLB in the same population.

TRIAL REGISTRATION

Prospectively registered with the Clinical Research Information Service on August 3, 2022; KCT0007599.

ChatGPT goes to the operating room: evaluating GPT-4 performance and its potential in surgical education and training in the era of large language models

Purpose

This study aimed to assess the performance of ChatGPT, specifically the GPT-3.5 and GPT-4 models, in understanding complex surgical clinical information and its potential implications for surgical education and training.

Methods

The dataset comprised 280 questions from the Korean general surgery board exams conducted between 2020 and 2022. Both GPT-3.5 and GPT-4 models were evaluated, and their performances were compared using McNemar test.

Results

GPT-3.5 achieved an overall accuracy of 46.8%, while GPT-4 demonstrated a significant improvement with an overall accuracy of 76.4%, indicating a notable difference in performance between the models (P < 0.001). GPT-4 also exhibited consistent performance across all subspecialties, with accuracy rates ranging from 63.6% to 83.3%.

Conclusion

ChatGPT, particularly GPT-4, demonstrates a remarkable ability to understand complex surgical clinical information, achieving an accuracy rate of 76.4% on the Korean general surgery board exam. However, it is important to recognize the limitations of large language models and ensure that they are used in conjunction with human expertise and judgment.

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

BACKGROUND

Liver transplant (LT) recipients were considered a vulnerable population during the coronavirus disease 2019 (COVID-19) pandemic. The clinical efficacy of the COVID-19 vaccine is unknown in immunocompromised patients. The purpose of this study was to provide evidence of antibody responses after COVID-19 vaccination in LT recipients.

METHODS

This study enrolled 46 patients who underwent LT at Samsung Medical Center (Seoul, Korea) before implementation of the one-dose vaccine in Korea. Those who completed the two-dose COVID-19 vaccine between August 2021 and September 2021 were included and followed through December 2021. Semiquantitative anti-spike serologic testing was performed using the Roche Elecsys anti-SARS-CoV-2 S enzyme immunoassay (Roche Diagnostics, Rotkereuz, Switzerland) with a positive cutoff of at least 0.8 U/mL.

RESULTS

Among all 46 participants, 40 (87%) demonstrated an antibody response after the second dose of a COVID-19 vaccine, while six (13%) had no antibody response after the second dose. Upon univariate analysis, patients with higher antibody titer had longer years since LT (2.3 ± 2.8 vs. 9.4 ± 5.0, P < 0.001). A lower median tacrolimus (TAC) level before vaccination and after the second dose of COVID-19 vaccine indicated a significantly higher antibody response (2.3 [1.6-3.2] vs. 7.0 [3.7-7.8], P = 0.006, 2.5 [1.6-3.3] vs. 5.7 [4.2-7.2], P = 0.003). Period between 2nd vaccination and serologic testing was significantly higher in the antibody-response group compared to the no-antibody-response group (30.2 ± 24.0 vs. 65.9 ± 35.0, P = 0.012). A multivariate analysis of antibody responses revealed TAC level before vaccination as a statistically significant factor.

CONCLUSION

A higher TAC level before vaccination resulted in less effective vaccination in LT patients. Booster vaccinations are required, especially for patients in the early stage after LT who have compromised immune function.

The Oncologic Implications of Tumor Multiplicity in Intrahepatic Cholangiocarcinoma: Its Prognostic Value Might Be Underestimated

Purpose

In the latest staging system of the American Joint Committee on Cancer (AJCC) for intrahepatic cholangiocarcinoma (IHCCC), solitary tumors with vascular invasion and multiple tumors are grouped together as T2. However, recent studies report that multifocal IHCCC has a worse prognosis than a single lesion. This study aimed to investigate the risk factors for IHCCC and explore the prognostic significance of multiplicity after surgical resection.

Materials and Methods

A total of 257 patients underwent surgery for IHCCC from 2010 to 2019 and the clinicopathological data were retrospectively reviewed. Risk factor analysis was performed to identify variables associated with survival after resection. Survival outcomes were compared between patients with solitary and multiple tumors.

Results

In multivariable analysis, the presence of preoperative symptoms, tumor size, lymph node ratio, multiplicity, and tumor differentiation were identified as risk factors for survival. Among 82 patients with T2, overall survival was significantly longer in patients with solitary tumors (sT2) than in those with multiple tumors (mT2) (p=0.017). Survival was compared among patients with stage II-sT2, stage II-mT2, and stage III. The stage II-sT2 group showed prolonged survival when compared with stage II-mT2 or stage III. Survivals of stage II-mT2 and stage III patients were not statistically different.

Conclusion

Tumor multiplicity was an independent risk factor for overall survival of IHCCC after surgical resection. Patients with multiple tumors showed poorer survival than patients with a single tumor. The oncologic significance of multiplicity in IHCCC should be reappraised and reflected in the next staging system update.

Detecting Donor-Derived DNA by Real-Time PCR in Recipients Suspected of Graft-Versus-Host-Diseases After Liver Transplantation: A Case Series and Literature Review

BACKGROUND Graft-versus-host disease (GVHD) after liver transplantation (LT) is a rare but fatal complication. GVHD diagnosis is usually based on clinical symptoms and pathologic confirmation. However, it is often misdiagnosed due to its non-specific symptoms. Here, we report the detection of donor-cell chimerism using peripheral blood (PB) donor-derived deoxyribonucleic acid (ddDNA) for 3 cases with suspected GVHD after LT (GVHD-LT) through real-time quantitative polymerase chain reaction (qPCR) assay targeting 39 insertions and/or deletions of chromosomes. MATERIAL AND METHODS The qPCR assay for detecting donor-cell chimerism was performed for 3 post-LT patients with suspected GVHD using KMRtype® and KMRtrack® assays (GenDx, Netherlands). The mean recipient/donor-cell fraction of informative markers unique to each recipient or donor was calculated. RESULTS In Case 1, who received living donor LT (LDLT) from his daughter, initial sign was diarrhea at post-operative day (POD) #23. Case 2 received unrelated deceased donor LT and initial sign was cytopenia at POD #29. Case 3 received LDLT from her son and GVHD associated cytopenia was developed at POD #80. Average PB ddDNA fractions in post-transplant samples of cases 1, 2, and 3 were 39.68%, 78.38%, and 4.76%, respectively. Despite an active treatment including steroid and tumor necrosis factor-alpha inhibitor, 2 patients (cases 1 and 2) died due to multiple organ failures. CONCLUSIONS Early detection of donor-cell chimerism may help halt fatal progression of GVHD-LT. A qPCR test targeting INDEL of chromosomes would be a helpful procedure for timely diagnosis of GVHD.

Contribution of Salvaged Blood Red Blood Cell Transfusion During Living Donor Liver Transplantation

BACKGROUND

Transfusion of allogeneic blood products can have adverse effects and profoundly influence postoperative liver transplantation outcomes, including graft survival. To minimize allogeneic red blood cell (RBC) transfusion, salvaged blood can be used during liver transplantation. The aim of this study was to determine the contribution of salvaged blood to allogeneic RBC transfusion in living donor liver transplantation (LDLT) recipients.

METHODS

Data of 311 adult-to-adult LDLT recipients between January 2015 and April 2019 were analyzed. The primary outcome was a change in requirement for allogeneic RBCs due to the use of salvaged blood. Additionally, predictors of intraoperative allogeneic RBC transfusion were investigated.

RESULTS

One hundred fifty-three (49.2%) recipients required allogeneic RBC transfusion. If recipients did not receive salvaged blood, 253 (81.4%) recipients would have needed allogeneic RBC transfusion. The total volume of salvaged blood transfused into recipients during surgery was 269,165 mL, which corresponded to 993 units of allogeneic RBCs and accounted for 76.1% of total RBC transfusion volume. Multivariate analysis showed that male recipients, model for end-stage liver disease score, preoperative hemoglobin level, and volume of salvaged blood used during surgery were independent predictors of the need for intraoperative allogenic RBC transfusion.

CONCLUSIONS

Intraoperative use of salvaged blood significantly reduced allogeneic RBC transfusion in LDLT recipients. It can help transplant teams manage transfusion of allogeneic RBCs during liver transplantation.

Fibrosis-4 index, a predictor for prognosis of hepatocellular carcinoma patients after curative hepatectomy even in hepatitis B virus dominant populations

Purpose

Liver fibrosis plays an important role in the development of hepatocellular carcinoma (HCC) and determining its prognosis. Although many staging systems and liver reserve models have been developed without the intention of predicting prognosis of HCC, some studies have investigated their prognostic values in HCC after curative liver resection (LR). The aim of this study is to evaluate prognostic value of non-invasive biomarkers after curative LR.

Methods

Between 2006 and 2013, HCC patients underwent LR were included and total 962 patients were enrolled. All non-invasive biomarkers (fibrosis 4 index (FIB-4), aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), AAR-to-platelet ratio index (AARPRI), and albumin-bilirubin (ALBI) score) were measured at the time of HCC diagnosis. To binarize each biomarker, an optimal cut-off value for fibrosis stage was selected using the value of minimum distance from the left-upper corner of the receiver operating characteristic curve with a specificity >60%. We performed Cox regression analysis on 2-year recurrence-free survival (RFS) and overall survival (OS).

Results

The area under curve values for FIB-4 and APRI were the largest for fibrosis stage compared to other biomarkers, 0.669 (95% confidential interval (CI), 0.610-0.719) and 0.748 (95% CI, 0.692-0.800), respectively. Between those two indices, FIB-4 is considered a statistically significant prognostic factor of RFS in HCC patients after LR. The HR for 2-year RFS and OS were 1.81 (95% CI, 1.18-2.77; P = 0.007) and 2.36 (95% CI, 0.99-5.65; P = 0.054), respectively.

Conclusion

FIB-4 is identified as a statistically significant predictor of HCC prognosis after curative LR even in HBV dominant populations.

First and second kidney transplantations from living donors offer comparable outcomes for patients

Background

Increasingly many patients are being relisted for repeat kidney transplantation due to longer survival times after transplantation. This study compared the outcomes of second living donor kidney transplantations (LDKTs) with those of first LDKTs.

Methods

Data were collected retrospectively for 1,429 LDKTs performed from 1995 to 2020 at Samsung Medical Center. The demographics of recipients and donors, immunologic factors, and outcomes of second LDKTs were compared to those of first LDKTs.

Results

Among 1,429 cases of LDKT, 1,355 were first LDKT cases and 74 were second LDKT cases. Basic demographic data were comparable for the two groups of patients. The 5- and 10-year graft survival rates were 94% and 84% for first LDKTs and 96% and 86% for second LDKTs, respectively, with neither difference statistically significant (P=0.399). The 5- and 10-year patient survival rates were 98% and 94% for the first and 96% and 93% for the second LDKTs, respectively; neither difference was statistically significant (P=0.766). Multivariate analysis confirmed that a history of previous transplantation was not a statistically significant risk factor for graft loss (hazard ratio [HR], 0.83; P=0.677) or patient death (HR, 1.68; P=0.396).

Conclusions

These results indicate that repeat kidney transplantation from living donors is a reasonable choice for patients who have experienced graft loss.

Indications for open hepatectomy in the era of laparoscopic liver resection: a high volume single institutional study

Background/Aim

Since the introduction of laparoscopy for liver resection in the 1990s, the performance of laparoscopic liver resection (LLR) has been steadily increasing. However, there is currently no data on the extent to which laparoscopy is used for liver resection. Herein, we investigated the extent to which laparoscopy is performed in liver resection and sought to determine whether surgeons prefer laparoscopy or laparotomy in the posterosuperior (PS) segment.

Methods

For this retrospective observational study, we enrolled patients who had undergone liver resection at the Samsung Medical Center between January 2020 and December 2021. The proportion of LLR in liver resection was calculated, and the incidence and causes of open conversion were investigated.

Results

A total of 1,095 patients were included in this study. LLR accounted for 79% of the total liver resections. The percentage of previous hepatectomy (16.2% vs. 5.9%, P<0.001) and maximum tumor size (median 4.8 vs. 2.8, P<0.001) were higher in the open liver resection (OLR) group. Subgroup analysis revealed that tumor size (median 6.3 vs. 2.9, P<0.001) and surgical extent (P<0.001) in the OLR group were larger than those in the LLR group. The most common cause of open conversion (OC) was adhesion (57%), and all OC patients had tumors in the PS.

Conclusions

We investigated the recent preference of practical surgeons in liver resection, and found that surgeons preferred OLR to LLR when treating a large tumor located in the PS.

Comparison of postoperative analgesic effects of posterior quadratus lumborum block and intrathecal morphine in laparoscopic donor hepatectomy: a prospective randomized non-inferiority clinical trial

Background

Posterior quadratus lumborum block (QLB) and intrathecal morphine are accepted analgesic strategies in laparoscopic liver resection, but their effects have not been compared after laparoscopic donor hepatectomy. This study was planned to perform this comparison.

Methods

Fifty-six donors were randomized to receive bilateral posterior (QLB2, 20 mL of 0.375% ropivacaine on each side, 150 mg total) or preoperative injection of 0.4 mg morphine sulfate intrathecally. Primary outcome was resting pain score at 24 hour postsurgery. Secondary outcomes included cumulative opioid consumption and recovery parameters. Serial plasma ropivacaine concentrations were measured in QLB group. Only the outcome assessor was properly blinded.

Results

Mean resting pain score at 24-hour postsurgery was 4.19±1.66 in QLB group (n=27) and 3.07±1.41 in intrathecal morphine group (n=27, p=0.04). Mean difference (QLB group-intrathecal morphine group) was 1.11 (95% CI 0.27 to 1.95), and the upper limit of CI was higher than prespecified non-inferiority margin (δ=1), indicating an inferior effect of QLB. Cumulative opioid consumption was significantly higher in QLB group at 24 hours and 48 hours postsurgery. QLB group exhibited lower incidence of postoperative pruritus at all time points, and there were no differences in other recovery outcomes. All measured ropivacaine concentrations were below the threshold for systemic toxicity (4.3 µg/mL).

Conclusions

Bilateral posterior QLB elicited higher resting pain scores at 24-hour after laparoscopic donor hepatectomy than intrathecal morphine and did not meet the definition of non-inferiority.

Trial registration number

KCT0005360.

3D Printing Model of Abdominal Cavity of Liver Transplantation Recipient to Prevent Large-for-Size Syndrome

The application of three-dimensional (3D) printing has been increasing and we invented cost-effective and time-saving 3D printed model of intra-abdominal cavity which was utilized in liver transplantation (LT) to prevent large-for-size syndrome. 3D printings were performed on potential adult recipients with small cavity and pediatric patients scheduled for transplantation during July 2020 – September 2021. Based on the computed tomography of the recipient, the inner surface of the abdominal cavity was outlined. The line was marked with a distance of 1 – 3 cm. Then, the outlined data were reconstructed as a 3D model and printed by a fused deposition modeling type 3D printer with a thickness of 2 mm. Pillars and footings for holding the lines were printed and assembled altogether. During deceased donor organ procurement, the size of the graft was compared to that of the printed model. For living donor LT, preoperatively planned liver graft was printed and was physically placed into the 3D printed abdominal cavity. All the 16 cases with 3D printed abdominal cavity showed appropriate fitting of the donor’s liver graft to both the 3D printed model and actual recipient’s abdominal cavity with no large-for-size syndrome after LT. Median time for manufacturing the model was 576 min (IQR 434 – 680) and estimated median cost for the filament was US$ 1.6 (IQR 1.2 – 1.7). The 3D printed abdominal cavity model can be manufactured in <10 h and was useful for preventing large-for-size syndrome in small-sized recipients.

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

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

Perioperative management of living donor liver transplantation: Part 2 - Donors

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation method has become a widely practiced and established transplantation option for adult patients suffering with end-stage liver disease, and it has successfully helped address the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplantation Anesthesiologists jointly reviewed published studies on the perioperative management of adult live liver donors undergoing donor hemi-hepatectomy. The goal of the review is to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live donors. We featured the current status, donor selection process, outcomes and complications, surgical procedure, anesthetic management, Enhanced Recovery After Surgery protocols, avoidance of blood transfusion, and considerations for emergency donation. Recent surgical advances, including laparoscopic donor hemi-hepatectomy and robotic laparoscopic donor surgery, are also addressed.