Woo Young Shin

An artificial vascular graft is a useful interpositional material for drainage of the right anterior section in living donor liver transplantation

Congestion in the anterior section in a right liver (RL) without a middle hepatic vein (MHV) may lead to graft dysfunction. To solve this problem, an RL draining MHV branches with autologous or cryopreserved vessels can be introduced. However, these vessels are often unavailable, and their preparation is time‐consuming. An expanded polytetrafluoroethylene (ePTFE) graft may be used for anterior section drainage. Between February and November 2005, 26 recipients underwent RL liver transplantation draining MHV branches with an ePTFE graft (group P). Twenty‐six ePTFE grafts (6 or 7 mm in internal diameter) drained 35 MHV branches on the back table to the graft right hepatic vein or to the recipients inferior vena cava. The patency of the ePTFE graft was checked with computed tomography scans of the liver. The outcome of group P was compared with those of an RL group with MHV (group M, n = 17) and an RL group without reconstruction of MHV or its tributaries (group R, n = 85). The 1‐month and 4‐month patency rates (PRs) of the ePTFE grafts were 80.8% (21/26) and 38.5% (10/26). All showing early obstruction of the ePTFE graft had congestion in the anterior section, but all showing late obstruction were asymptomatic. The 1‐month PRs of group P were comparable to, but the 4‐month PRs were lower than, those of group M (both 94.1%; P < 0.05). However, 1‐year patient and graft survival rates of group P (both 100%) were comparable to those of group M (94.1% and 100%) and better than those of group R (83.5% and 88.2%; P < 0.05). In conclusion, the early PR of group P was good, and late obstruction of the ePTFE graft had no impact on congestion in the anterior section or patient survival. Therefore, an ePTFE graft may be a useful interposition material for anterior section drainage in RL transplantation without serious complications. Liver Transpl 13:1159–1167, 2007.

Classification and prognosis of intrahepatic biliary stricture after liver transplantation.

Intrahepatic biliary stricture (IHBS) after liver transplantation (LT) may develop in patients with hepatic artery thrombosis, chronic rejection, or ABO incompatibility, as well as in patients with prolonged warm ischemia in non‐heart‐beating donor (NHBD) LT. However, the clinical course and methods of management have not been well defined for IHBSs to date. Thus, the purpose of this study was to provide a classification of post‐LT IHBS and to investigate patient prognosis. Forty‐four patients who developed IHBS after NHBD LT were enrolled. On the basis of the cholangiographic appearance, patients were classified into 4 groups: unilateral focal (UF, n = 8), confluence (CO, n = 10), bilateral multifocal (BM, n = 21), and diffuse necrosis (DN, n = 5). The UF type was defined as cases with stricture only in the segmental branch of the unilateral hemiliver; the CO type in cases with several strictures at confluence level; and the BM type in cases with multiple strictures bilaterally. Cases with diffuse obliteration of peripheral ducts or destruction of the central architectural integrity, over a long segment, were classified as the DN type. Five patients with the CO type required several interventions requiring biliary dilatation, yet all patients with the UF or CO type had a good prognosis. Among the patients with the BM type, 3 patients (14.3%) died or underwent retransplantation due to biliary complications, and 7 (33.3%) required repeated interventions for >1 year without improvement. Moreover, among 5 patients classified as the DN type, 1 (20%) died of biliary sepsis, 2 (40%) underwent retransplantation, and the remaining 2 (40%) did not recover from persistent jaundice and life‐threatening cholangitis despite multiple interventions. In conclusion, all patients classified as UF or CO had a good outcome with or without additional interventions. However, all patients with the DN type and about half the patients with the BM type did not recover from life‐threatening complications, despite repeated aggressive interventions; early retransplantation was therefore the only treatment option for these patients. Liver Transpl 13:1736–1742, 2007.

Laparoscopy-Assisted Donor Right Hepatectomy Using a Hand Port System Preserving the Middle Hepatic Vein Branches

BackgroundThis report reviews our experience with a modified right hepatectomy (MRH) using laparoscopic or laparoscopy-assisted techniques preserving the middle hepatic vein (MHV) branches in living donor liver transplantation.MethodsNine female donors (17–36xa0years) underwent a laparoscopic MRH under pneumoperitoneum (L-MRH; nxa0=xa02) or a laparoscopy-assisted MRH (LA-MRH; nxa0=xa07) with a hand port device. The donors for this minimally invasive surgery were volunteers with the willingness to undergo laparoscopic surgery and recipients who were not in urgent need of transplantation. Mobilization of the right liver was performed under pneumoperitoneum in all cases. Hilar dissection and parenchymal transection were performed under pneumoperitonuem (nxa0=xa02) or with a mini-laparotomy incision (nxa0=xa07) using an ultrasonic aspirator without the Pringle maneuver. The major MHV branches (>5xa0mm) were preserved using Hem-o-lock clips. The graft was extracted through the site of the hand port device or the mini-laparotomy. On the back table, the MHV branches were reconstructed with an artificial vascular graft.ResultsThere were no open conversions, and the graft was transplanted without any problem in every case. The operative time for the donors was 765xa0min and 898xa0min in the L-MRH patients, and it ranged from 310 to 575xa0min for the laparoscopy-assisted surgery. None of the donors required transfusion or reoperation; they were discharged on postoperative day 8–14 with normal liver function. A major complication occurred in one donor; fluid collection along the liver resection margin with fever was treated and resolved after percutaneous drainage.ConclusionsA right hepatectomy preserving the MHV or its branches by minimally invasive techniques including total laparoscopic surgery was technically feasible. However, further refinements of the procedure are required prior to wide clinical application.

Prognostic factors affecting survival after recurrence in adult living donor liver transplantation for hepatocellular carcinoma

Liver transplantation is regarded as an effective treatment for early hepatocellular carcinoma (HCC). However, some patients experience recurrence and subsequently rapid progression of the disease. We investigated prognostic factors affecting survival after recurrence in patients who underwent adult living donor liver transplantation (LDLT) for HCC. From October 1992 to December 2005, 138 adult patients underwent LDLT for HCC. Among these, 28 patients (20.3%) who suffered recurrence were retrospectively reviewed. Univariate and multivariate analyses were performed to analyze factors affecting survival after recurrence. The median time to recurrence was 7.9 months. The median survival time after recurrence was 11.7 months, and the 1‐ and 3‐year survival rates after recurrence were 52.8% and 15.8%, respectively. Initially, 7 patients (25%) showed multiorgan involvement; however, in the follow‐up, 21 patients (75%) had multiorgan involvement. On univariate analysis, a pretransplant alpha‐fetoprotein level >1000 ng/mL, major vascular invasion, a poorly differentiated tumor, a time to recurrence ≤6 months, unresectable disease, and bony metastases were related to shorter survival after recurrence. The independent prognostic factors by multivariate analysis were major vascular invasion [hazard ratio (HR) = 7.6], a poorly differentiated tumor (HR = 4.3), unresectable disease (HR = 10.4), and bony metastases (HR = 3.2). Two patients survived more than 36 months. One of them underwent retransplantation and survived for 45 months without additional recurrences. In conclusion, after transplantation, recurrent HCC has a tendency to involve multiple organs, and the prognosis is very poor. However, some patients have a good prognosis, and the appropriate treatment can prolong their survival. If the recurrent lesion is locally controllable, surgical resection should be considered. Liver Transpl 16:678‐684, 2010.

Improved outcome of adult recipients with a high model for end-stage liver disease score and a small-for-size graft.

Although adult‐to‐adult living donor liver transplantation (ALDLT) has shown comparable outcomes to deceased donor liver transplantation, the outcome of patients with a high MELD score (>25) and a small‐for‐size graft (SFSG<0.8% of graft‐to‐recipient weight ratio) is not known. For 7 years, 167 consecutive hepatitis B virus‐infected recipients underwent ALDLT at our institution. Based on their MELD score without additional score for hepatocellular carcinoma (HCC), the recipients were divided into Group L (low MELD score, n = 105) or Group H (high MELD score, n = 62). To analyze the risk of the graft size, the patients were further stratified as follows: Group Hs (high MELD score and SFSG, n = 11), Hn (high MELD score and normal size graft, n = 51), Ls (low MELD score and SFSG, n = 18), and Ln (low MELD score and normal size graft, n = 87). The primary endpoint was one‐year patient survival rate (1‐YSR). The mean follow‐up period was 32.6 months. The mean MELD scores were 17.1 in Group L and 32.6 in Group H. Group H had more patients with the complications of cirrhosis but less patients with HCC than Group L (p < 0.05). However, major morbidity rates and 1‐YSR were similar in comparisons between Group L (46.7% and 86.7%) and H (59.7% and 83.8%) (p > 0.05). 1‐YSR was similar among Group Hs (72.7%), Hn (86.3%), Ls (83.3%), and Ln (88.5%) groups (p = 0.278). The multivariate analysis revealed accompanying HCC and the year of transplant were risk factors for poor 1‐YSR. However, 1‐YSR without HCC patients was also similar in comparisons between group L (90.2%) and H (91.7%) (p = 0.847), and among Group Hs (80.0%), Hn (94.7%), Ls (72.7%), and Ln (96.7%) (p = 0.072). In conclusion, high MELD score (>25) didnt predict 1‐YSR in ALDLT. Improvement of the 1‐YSR might be affected by centers experience as well as the selection of patients with low risk of recurrence of HCC. Liver Transpl 15:496–503, 2009.

Platelet Transfusion can be Related to Liver Regeneration After Living Donor Liver Transplantation

BackgroundAlthough liver regeneration is a fundamental aspect of living donor liver transplantation (LDLT), the factors that affect liver regeneration during the early post-transplantation period have not been thoroughly investigated. Recently it was suggested that platelets contribute to liver regeneration. The aim of the present study was to identify the major factors that affect liver graft regeneration during the early post-transplantation period.Materials and methodsEighty-seven right liver grafted, adult-to-adult LDLT patients were retrospectively analyzed. Liver regeneration was assessed by volumetry from computed tomographic (CT) scans obtained between the 9th and 11th postoperative days. The authors investigated relationships between clinical variables and liver graft regeneration rates, and they conducted multiple regression analysis on factors found to be significant by univariate analysis.ResultsMean graft weight at operation was 722.9xa0±xa0109.7xa0g, and mean graft volume assessed by follow-up CT was 1,042.2xa0±xa0155.6xa0ml, reflecting a mean liver graft regeneration of 45.9xa0±xa022.3%. The graft regeneration was found to correlate inversely with graft-to-recipient weight ratio (GRWR, rxa0=xa0−0.406, pxa0<xa00.001) and directly with portal flow velocity (cm/s; rxa0=xa00.307; pxa0=xa00.004) and splenic index (cm3; rxa0=xa00.282; pxa0=xa00.009). Moreover, the total amount (units) of platelets transfused was found to be significantly associated with graft regeneration (rxa0=xa00.293; pxa0=xa0−.006). Stepwise regression analysis showed that GRWR (βxa0=xa0−33.124; pxa0=xa00.001), total amount of platelets transfused (βxa0=xa00.771; pxa0=xa00.012), and splenic index (βxa0=xa0−0.010; pxa0=xa00.049) were independently associated with graft regeneration.ConclusionsThe results of the present study suggest that platelets play a significant role in human liver regeneration after LDLT.

Current role of surgery in treatment of early stage hepatocellular carcinoma: resection versus liver transplantation.

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and is most commonly associated with hepatitis B infection in Korea. Although liver resection is regarded as a potentially curative treatment option, it is only feasible in less than 20% of patients. The reason for this is that HCC arises in cirrhotic livers and is often multicentric. Liver transplantation (LT) which could be used in the treatment both of the tumor and background liver seems to be a rational approach for early stage patients with decompensated liver cirrhosis. Current good selection criteria of LT for HCC are the Milan criteria: 1 HCC nodule ≤5 cm in diameter or 3 nodules ≤3 cm. By restricting LT to patients within the Milan criteria, the 4-year disease-free survival rate was more than 80%, which is comparable to that of a transplant candidate without HCC. However, there are serious limitations for the wider application of LT for HCC: (1) organ shortage, (2) risk to a live donor, (3) high cost, and (4) lifelong immunosuppression. For this reason, for a patient with early stage HCC and with Child A cirrhosis in whom partial hepatectomy is possible, the choice of primary treatment with curative intent is still under debate.

Liver transplantation for hepatocellular carcinoma in patients who do not meet the Milan criteria.

Background: To expand the Milan criteria, prognostic factors other than size and number of tumor may be necessary. We analyzed outcome and prognostic factors in patients with hepatocellular carcinoma (HCC) exceeding Milan criteria to select favorable group of patients. Methods: Between November 1997 and December 2005, 104 cases of liver transplantation for patients with HCC were performed at our center. Twenty-four patients did not meet the Milan criteria preoperatively. Among these 24 patients, 19 had no major vascular invasion at the time of surgery. We analyzed the survival and prognostic factors of these 19 patients. The mean follow-up period was 33 months (range 6–89). Results: Three-year survival rate in 19 patients was 67.4%. Three-year survival rates were significantly higher when preoperative alpha-fetoprotein was less than 400 ng/ml (86.2 vs. 0%, p<0.001) when Edmonson-Steiner’s histological grade 1 or 2 (100 vs. 40%, p = 0.036) and when microvascular invasion was absent (78.6 vs. 30%, p = 0.039). Conclusion: If vascular invasion is absent in preoperative radiological studies, and the preoperative alpha-fetoprotein is less than 400 ng/ml, our findings suggest a good prognosis after liver transplantation for HCC patients who do not meet the Milan criteria.

Thrombosis confined to the portal vein is not a contraindication for living donor liver transplantation

BackgroundThere is a lack of agreement regarding preexisting portal vein thrombosis (PVT) in patients undergoing living donor liver transplantation (LDLT). We report the results of a single-center study to determine the impact of PVT on outcomes of adult LDLT recipients.MethodsOf 133 cases of adult LDLT performed between January 2000 and December 2004, a thrombectomy was performed on 22 patients (16.5%) with PVT during the transplant procedure. One hundred eleven patients without PVT (group 1) were compared with those with a thrombosis confined to the portal vein (group 2; nxa0=xa015) and patients with the thrombosis beyond the portal vein (group 3; nxa0=xa07).ResultsThe sensitivities of Doppler ultrasound and CT in detecting PVT were 50 and 63.6%. A prior history of variceal bleeding (ORxa0=xa010.6, pxa0=xa00.002) and surgical shunt surgery (ORxa0=xa028.1, pxa0=xa00.044) were found to be an independent risk factors for PVT. The rate of postoperative PVT was significantly higher in patients with PVT than in those without (18.2 vs. 2.7%; pxa0=xa00.014). In particular, the rethrombosis rate in group 3 was 28.6%. The actuarial 3-year patient survival rate in PVT patients (73.6%) was similar to that of the non-PVT patients (85.3%; pxa0=xa00.351). However, the actuarial 3-year patient survival rate in group 3 was 38.1%, which was significantly lower than that in groups 1 and 2 (pxa0=xa00.006).ConclusionA thrombosis confined to the portal vein per se should not be considered a contraindication for LDLT.

Laparoscopic Hepatectomy for a Modified Right Graft in Adult-to-Adult Living Donor Liver Transplantation

BACKGROUNDnWe performed a modified right hepatectomy completely by laparoscopic techniques preserving the middle hepatic vein (MHV) branches in adult-to-adult living donor liver transplantation (LDLT).nnnPATIENTS AND METHODSnTwo young women (24 and 25 years old) volunteered to be live donors for their parents who had hepatocellular carcinomas. As the donors expressed concerns about scarring, we performed a laparoscopic procedure using a hand port device. Mobilization of the right liver and the hepatic parenchymal transection were performed under pneumoperitoneum. Parenchymal transection was performed using a laparoscopic ultrasonic aspirator without the Pringle maneuver. During parenchymal transection, major MHV branches >5 mm were preserved using Hem-o-lock clips. The graft was extracted through the hand port site. On the back table, the 3 MHV branches were reconstructed using an artificial vascular graft. The livers were transplanted without complications.nnnRESULTSnThe operative times for the donors were 765 and 898 minutes. The donors did not require transfusions or reoperation; they were discharged on postoperative days 10 and 14 with normal liver functions.nnnCONCLUSIONnA hepatectomy performed completely by laparoscopic techniques for a right graft with preservation of the MHV branches was technically feasible.