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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.

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

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.

A right liver graft with multiple hepatic artery (HA) stumps can be found in approximately 5% of living donor liver transplantation (LDLT) using a right lobe graft. From January 2000 to June 2014, 1149 patients underwent LDLT procedures. Thirty patients with LDLT using a right lobe graft with multiple HA stumps and 149 patients with LDLT using a right lobe graft with a single HA stump were enrolled. These patients were divided into 3 groups: single HA (group 1, n = 149), multiple HAs with total reconstruction (group 2, n = 19), and multiple HAs with selective partial reconstruction (group 3, n = 11). Selective partial reconstruction was performed only when pulsatile back-bleeding was confirmed after larger HA reconstruction and sufficient intrahepatic arterial flow was confirmed by Doppler ultrasound (DUS). In group 2, the donor HAs were smaller (P < .001), and HA reconstruction took longer (P < .001). However, there was no significant difference among the groups regarding the arterial complication rate, biliary complication rate, and patient and graft survival. In conclusion, selective partial reconstruction of HA stumps for LDLT using a right lobe graft was feasible when intrahepatic arterial communication was confirmed by pulsatile back-bleeding from the smaller artery and DUS. Liver Transplantation 22 1649-1655 2016 AASLD.

The use of hepatitis B core antibody-positive (HBcAb+) grafts for liver transplantation (LT) has the potential to safely expand the donor pool, as long as proper prophylaxis against de novo hepatitis B (DNHB) is employed. The aim of this study was to characterize the longterm outcome of pediatric LT recipients of HBcAb + liver grafts under a prophylaxis regimen against DNHB using hepatitis B virus (HBV) vaccine and hepatitis B immunoglobulin (HBIG). From June 1996 to February 2013, 49 patients receiving pediatric LT at our center were from HBcAb + donors. Forty-one patients who received DNHB prophylaxis according to our protocol were included in this analysis. Our DNHB prophylaxis protocol consists of HBV vaccine intramuscular injections given intermittently to maintain anti-hepatitis B surface antibody (HBsAb) titers above 100 IU/L. HBIG was also used during the first posttransplant year with a target anti-HBsAb titer level above 200 IU/L. There were 19 boys and 22 girls. Median age was 1.0 year (range, 4 months to 16 years). Median follow-up time was 66 months after transplant. Median annual number of HBV vaccine injections was 0.8 per year (range, 0-1.8 per year). Four patients did not require any HBV vaccine injections during follow-up. One patient with DNHB was encountered during the follow-up period (1/41, 2.4%). DNHB was diagnosed at 3.5 years after transplant, when hepatitis B surface antigen was positive upon routine follow-up serologic testing. Anti-HBsAb titer was 101.5 IU/L at the time. No grafts were lost because of DNHB-related events. Overall survival of the 41 recipients of HBcAb + grafts who received DNHB prophylaxis was 92.3% at 10 years after transplant. In conclusion, longterm prophylaxis against DNHB with HBV vaccine in pediatric LT recipients of HBcAb + grafts was safe and effective in terms of DNHB incidence as well as graft and patient survival.

Simplifying the therapeutic regimen of liver transplantation (LT) recipients may help prevent acute rejection and graft failure. The present study aimed to evaluate the efficacy and safety of conversion from twice-daily tacrolimus to once-daily extended-release tacrolimus under concurrent mycophenolate mofetil therapy in stable LT recipients. This randomized, prospective, controlled study included 91 patients who underwent LTs with at least 1 year of posttransplant follow-up. Conversion was made on a 1 mg to 1 mg basis. No incidences of biopsy-proven acute rejection, graft failure, or death were reported in either group at 24 weeks. Median serum tacrolimus level of the study group was 20% less than that of the control group at 8 weeks. However, no significant differences regarding biochemical indicators of liver function or serum creatinine levels were observed between the 2 groups. Adverse event (AE) profiles were similar for both groups, with comparable incidences of AEs and serious AEs. No significant differences regarding efficacy or safety were observed between the once-daily tacrolimus and twice-daily tacrolimus groups of stable LT recipients. In conclusion, our study suggests that tacrolimus can be safely converted from a twice-daily regimen to a once-daily regimen in stable LT recipients.

Intermittent hepatic inflow occlusion (IHIO) during liver graft procurement is known to confer protection against graft ischemia/reperfusion injury and thus may benefit the recipient's outcome. We evaluated whether the protective effect of IHIO differs with the presence of macrosteatosis (MaS) and with an increase or decrease in the cumulative occlusion time. The subgroup of 188 recipients who received grafts with MaS was divided into 3 groups according to the number of total IHIO rounds during graft procurement: no IHIO, n = 70; 1 to 2 rounds of IHIO, n = 50; and ≥3 rounds of IHIO, n = 68. Likewise, the subgroup of 200 recipients who received grafts without MaS was divided into 3 groups: no IHIO, n = 108; 1 to 2 rounds of IHIO, n = 40; and ≥3 rounds of IHIO, n = 52. The Cox model was applied to evaluate the association between the number of total IHIO rounds and recipient survival separately in the subgroup of MaS recipients and the subgroup of non-MaS recipients. Analyzed covariables included the etiology, Milan criteria, transfusion, immunosuppression, and others. In the subgroup of MaS recipients, 1 to 2 rounds of IHIO were favorably associated with recipient survival [hazard ratio (HR), 0.29; 95% confidence interval (CI), 0.10-0.80; P = 0.03 after Bonferroni correction], whereas ≥3 rounds of IHIO were not associated with recipient survival (HR, 0.56; 95% CI, 0.25-1.23). In the subgroup of non-MaS recipients, neither 1 to 2 rounds of IHIO (HR, 0.69; 95% CI, 0.30-1.61) nor ≥3 rounds of IHIO (HR, 0.91; 95% CI, 0.42-1.96) were associated with recipient survival. In conclusion, 1 to 2 rounds of IHIO may be used for the procurement of MaS grafts with potential benefit for recipient survival, whereas IHIO has a limited impact on recipient survival regardless of the cumulative occlusion time when it is used for non-MaS grafts. Liver Transpl 21:644–651, 2015. © 2015 AASLD.

Salvage liver transplantation (LT) is considered a feasible option for the treatment of recurrent hepatocellular carcinoma (HCC). We performed this multicenter study to assess the risk factors associated with the recurrence of HCC and patient survival after salvage LT. Between January 2000 and December 2011, 101 patients who had previously undergone liver resection (LR) for HCC underwent LT at 3 transplant centers in Korea. Sixty-nine patients' data were retrospectively reviewed for the analysis. The recurrence of HCC was diagnosed at a median of 10.6 months after the initial LR, and patients underwent salvage LT. Recurrences were within the Milan criteria in 48 cases and were outside the Milan criteria in 21 cases. After salvage LT, 31 patients had HCC recurrence during a median follow-up period of 24.5 months. There were 24 deaths, and 20 were due to HCC recurrence. The 5-year overall survival rate was approximately 54.6%, and the 5-year recurrence-free survival rate was 49.3%. HCC recurrence within the 8 months after LR [hazard ratio (HR) = 3.124, P = 0.009], an alpha-fetoprotein level higher than 200 ng/mL (HR = 2.609, P = 0.02), and HCC outside the Milan criteria at salvage LT (HR = 2.219, P = 0.03) were independent risk factors for poor recurrence-free survival after salvage LT. In conclusion, the timing and extent of HCC recurrence after primary LR both play significant roles in the outcome of salvage LT. Liver Transpl 20:1057-1063, 2014. © 2014 AASLD.

A safe use of intermittent hepatic inflow occlusion (IHIO) has been reported for living donor hepatectomy. However, it remains unclear whether the maneuver is safe in steatotic donors. In addition, the respective importance of macrosteatosis (MaS) and microsteatosis (MiS) is an important issue. Thus, we compared MiS and MaS with respect to the tolerance of hepatic ischemia/reperfusion (IR) injury induced by IHIO. One hundred forty-four donors who underwent a right hepatectomy were grouped according to the presence of MaS and MiS: a non-MaS group (n = 68) versus an MaS group (n = 76) and a non-MiS group (n = 51) versus an MiS group (n = 93). The coefficients of the regression lines between the cumulative IHIO time and the peak postoperative transaminase concentrations were used as surrogate parameters indicating the tolerance of hepatic IR injury. The coefficients were significantly greater for the MaS group versus the non-MaS group (4.12 ± 0.59 versus 2.22 ± 0.46 for alanine aminotransferase, P = 0.01). Conversely, the MiS and non-MiS groups were comparable. A subgroup analysis of donors who underwent IHIO for >30 minutes showed that MaS significantly increased the transaminase concentrations, whereas MiS had no impact. Also, IHIO for >30 minutes significantly increased the biliary complication rate for MaS donors (12.1% for ≤ 30 minutes versus 32.6% for >30 minutes, P = 0.04), whereas MiS donors were not affected. In conclusion, the tolerance of hepatic IR injury might differ between MaS livers and MiS livers. It would be rational to assign more clinical importance to MaS versus MiS. We further recommend limiting the cumulative IHIO time to 30 minutes or less for MaS donors undergoing right hepatectomy.

Postoperative analgesia and care for living liver donors have become particular interests for clinicians as the use of living donor liver transplantation has increased. Local anesthetic-based analgesia has been known to provide effective pain control. In this prospective, randomized study, we compared the postoperative analgesic efficacy of local anesthetic-based analgesia (PainBuster) with the efficacy of opioid-based analgesia [intrathecal morphine (ITM) with intravenous (IV) fentanyl] in liver donors. Forty adult donors were randomly allocated to 1 of 2 groups: an ITM/IV fentanyl group (n = 21) and a PainBuster group (n = 19). Donors in the PainBuster group received 0.5% ropivacaine via a multi-orifice catheter (ON-Q PainBuster) placed at the wound. Donors in the ITM/IV fentanyl group received ITM sulfate (400 μg) preoperatively and a continuous IV fentanyl infusion postoperatively. A visual analogue scale (VAS) at rest and with coughing and rescue IV fentanyl and meperidine consumption were assessed for 72 hours after the operation. Side effects, including sedation, dizziness, nausea, vomiting, pruritus, respiratory depression, wound seroma or hematoma, and the first time to flatus, were recorded. The VAS score at rest during the first 12 postoperative hours was significantly lower for the ITM/IV fentanyl group. At other times, the VAS scores were comparable between the groups. In the PainBuster group, rescue IV fentanyl and meperidine use was significantly reduced 24 to 48 hours and 48 to 72 hours after surgery in comparison with the first 24 postoperative hours. The time to first flatus was significantly reduced in the PainBuster group. There were no differences in side effects. In conclusion, analgesia was more satisfactory with ITM/IV fentanyl versus PainBuster during the first 12 hours after surgery, but they became comparable thereafter, with a shortened bowel recovery time in the PainBuster group. The concurrent use of ITM with PainBuster may be considered in a future investigation.

To evaluate the effects of intermittent hepatic inflow occlusion (IHIO) during donor hepatectomy for living donor liver transplantation (LDLT) in recipients and donors, we performed a single-center, open-label, prospective, parallel, randomized controlled study. Adult donor-recipient pairs undergoing LDLT with right hemiliver grafts were randomized into IHIO and control groups (1:1). In the IHIO group, IHIO was performed during donor hepatectomy. The primary endpoint was the peak serum alanine aminotransferase (ALT) concentration in the recipients within 5 days after the operation. Blood samples for measurements of interleukin-6 (IL-6), IL-8, tumor necrosis factor α (TNF-α), and hepatocyte growth factor (HGF) were taken from the donors and the recipients during the operation and postoperatively. Biopsy samples for measurements of caspase-3 and malondialdehyde (MDA) were taken from the donors and the recipients. In all, 50 donor-recipient pairs (ie, 25 pairs in each group) completed this study. The mean peak serum ALT levels within 5 days after the operation did not differ in the recipients between the 2 groups (P = 0.32) but were higher in the donors of the IHIO group (P = 0.002). There were no differences in the prothrombin times or total bilirubin levels in the recipients or donors between the 2 groups. The amount of blood loss during donor hepatectomy was significantly lower in the IHIO group versus the control group (P = 0.02). The mean hospital stay for donors was 19.3 ± 7.2 days in the control group and 15.8 ± 4.6 days in the IHIO group (P = 0.046). There were no in-hospital deaths within 1 month and no cases of primary nonfunction or initially poor function in the 2 groups. The concentrations of IL-6, IL-8, TNF-α, and HGF did not differ between the 2 groups, nor did the concentrations of caspase-3 and MDA. In conclusion, although we found differences in postoperative peak serum ALT levels in donors, donor hepatectomy with IHIO for LDLT using a right hemiliver graft with a graft-to-recipient body weight ratio > 0.9% and

Biliary strictures are a major cause of morbidity and mortality for liver transplant recipients. The endoscopic management of biliary strictures is not well established after living donor liver transplantation (LDLT) in comparison with deceased donor liver transplantation. The aims of this study were to assess the initial success rate of primary endoscopic treatment of biliary strictures after LDLT and to identify predictors of the feasibility of endoscopic management. One hundred thirty-seven adult patients who underwent LDLT and were confirmed to have biliary strictures by endoscopic retrograde cholangiopancreatography (ERCP) were enrolled. The biliary strictures were primarily managed endoscopically with internal drainage or nasobiliary catheterization. The initial success rate for the primary endoscopic management of biliary strictures after LDLT was 46.7% (64 of 137 patients), and the feasibility of endoscopic management was associated with the stricture-to-ERCP interval (the interval between the development of the total bilirubin, aspartate aminotransferase, or alanine aminotransferase level to >2 times the upper limit of normal and the performance of ERCP) as well as cholangiographic findings (eg, the stricture morphology and the tip shape of the distal duct). In conclusion, when biliary strictures are noticed after LDLT, prompt endoscopic interventions may improve the initial success rate of primary endoscopic management. In addition, the feasibility of primary endoscopic management can be predicted by the cholangiographic findings, which may help with the choice of the therapeutic modality. Liver Transpl, 2011. © 2011 AASLD.

Cytomegalovirus (CMV) infections contracted after liver transplantation put patients at an increased risk of morbidity and mortality. We analyzed the effects of CMV infection by time of onset, mortality, and graft failure risk factors in liver recipients who were CMV donor-positive/recipient-positive (D+/R+). We reviewed 618 medical records for consecutive adult liver transplant cases. CMV pp65 antigenemia assays to determine patient CMV status were administered monthly. The incidences of CMV infection and disease were 55.7% (344 of 618 records) and 5.5% (34 of 618 records), respectively. The differences in patient survival and graft failure rates for CMV-infected and CMV-uninfected patients were not significant (P = 0.707 and P = 0.973), but the rates were lower in patients with CMV disease than in CMV-uninfected patients (P = 0.005 and P = 0.030, respectively). The recurrence of hepatitis B virus and hepatocellular carcinoma, hepatic dysfunction, infection, numerous pp65-staining cells, and CMV disease were found to be the risk factors for mortality and graft failure in CMV D+/R+ adult liver transplant patients. In conclusion, the occurrence of CMV disease, and not asymptomatic CMV infection, was a risk factor for mortality and graft failure in adult liver transplant recipients with CMV D+/R+.

The problem of graft size is one of the critical factors limiting the expansion of adult-to-adult living donor liver transplantation (LDLT). We compared the outcome of LDLT recipients who received grafts with a graft-to-recipient weight ratio (GRWR) < 0.8% or a GRWR ≥ 0.8%, and we analyzed the risk factors affecting graft survival after small-for-size grafts (SFSGs) were used. Between June 1997 and April 2008, 427 patients underwent LDLT with right lobe grafts at the Department of Surgery of Samsung Medical Center. Recipients were divided into 2 groups: group A with a GRWR < 0.8% (n = 35) and group B with a GRWR ≥ 0.8% (n = 392). We retrospectively evaluated the recipient factors, donor factors, and operative factors through the medical records. Small-for-size dysfunction (SFSD) occurred in 2 of 35 patients (5.7%) in group A and in 14 of 392 patients (3.6%) in group B (P = 0.368). Graft survival rates at 1, 3, and 5 years were not different between the 2 groups (87.8%, 83.4%, and 74.1% versus 90.7%, 84.5%, and 79.4%, P = 0.852). However, when we analyzed risk factors within group A, donor age and middle hepatic vein tributary drainage were significant risk factors for graft survival according to univariate analysis (P = 0.042 and P = 0.038, respectively). Donor age was the only significant risk factor for poor graft survival according to multivariate analysis. The graft survival rates of recipients without SFSD tended to be higher than those of recipients with SFSD (85.3% versus 50.0%, P = 0.074). The graft survival rates of recipients with grafts from donors < 44 years old were significantly higher than those of recipients with grafts from donors ≥ 44 years old (92.2% versus 53.6%, P = 0.005). In conclusion, an SFSG (GRWR < 0.8%) can be used safely in adult-to-adult right lobe LDLT when a recipient is receiving the graft from a donor younger than 44 years. Liver Transpl 16:864–869, 2010. © 2010 AASLD.

To overcome the barrier of size match, right lobe graft has been widely used in living donor liver transplantation (LDLT). We assessed donor outcome, with a focus on remnant liver volume (RLV) after right hepatectomy based on the experiences of 2 LDLT centers, as a means of guiding the establishment of safe RLV limits for donor right hepatectomy. Between January 2002 and December 2003, a consecutive 146 liver donors who underwent right hepatectomy with at least 12 months of follow-up were enrolled in this study. Donors were grouped into 2 groups according to RLV: group 1 (n = 74)