Over 500 Liver Transplants Including More Than 400 Living-Donor Liver Transplants in 2019 at Asan Medical Center

Comparison between Japan and Korea in liver transplantation: Focusing on a higher deceased donation rate in Korea

Over the past 30 years, liver transplantations (LTs) and deceased-donor LTs (DDLTs) have been higher in Korea than in Japan. In 2019, the number of DDLT reached 88 (22.3% of LTs) in Japan and 391 (24.7% of LTs) in Korea. The deceased-donor rate (per million population) was 0.70 in Japan and 7.56 in Korea. Presently, Korea is one of the Asian countries with the highest rate of DDLT. Factors conducive to the deceased donation rate in Korea encompass the socio-legal system, including the Korean Network for Organ Sharing, Korean Organ Donation Agency, the healthcare system and public awareness. During 2009-2019, two major indications of DDLT were hepatitis B cirrhosis and alcoholic liver disease in Korea, and acute liver failure and metabolic diseases in Japan. For living-donor LT, two major indications were hepatitis B cirrhosis and neoplastic diseases in Korea, and biliary atresia and neoplastic diseases in Japan. During the COVID-19 pandemic, the indications for DDLT in Korea were alcoholic liver disease and hepatitis B cirrhosis with a higher rate of alcoholic liver disease than during the pre-pandemic period. In 2021, the 5-year survival rate of DDLT was 66.5% in Korea compared with 82.6% in Japan, whereas that rate of living-donor LT in Korea reached 80.8% compared with 79.4% in Japan. To promote LT in Japan and Korea, mutual understanding and intercommunication between the two countries is crucial.

No-touch recipient hepatectomy in liver transplantation for liver malignancies: A state-of-the-art review

Tumor recurrence, the Gordian knot of liver transplantation for malignancies, may be attributed to many parameters. The technique of the "classical" recipient hepatectomy is believed to be one of the potential reasons to cause tumor evasion because of the possible increase of circulating tumor cells, thus leading to an increased recurrent rate. On this background, the no-touch oncological recipient hepatectomy technique has been developed. A comprehensive review of the development and the key surgical steps of the no-touch recipient hepatectomy is presented. This technique might improve clinical outcomes, especially for those recipients who are at a high risk for tumor recurrence. Multicenter prospective studies should be set up to further validate the prognostic role of this technique in patients with liver cancer treated with liver transplantation.

Multiple Swaps Tested: Rehearsal for Triple and Five Liver Paired Exchanges

Despite several advances in living donor liver transplant (LDLT), many potential living liver donors cannot donate their organs to their relatives because of blood group incompatibility and unsuitable anatomy. Liver paired exchange (LPE) can be used to overcome incompatibilities between living donor-recipient pairs. In this study, we report the early and late results of three and five LDLTs performed simultaneously to initiate the more complex LPE program. By demonstrating that our center is capable of performing up to five LDLTs, we have taken an essential step for establishing a complex LPE program.

Impact of Chronic Hepatitis C Virus on Acute Kidney Injury After Living Donor Liver Transplantation

BACKGROUND

Acute kidney injury (AKI) is one of the most common complications after liver transplantation (LT) and can significantly impact outcomes. The presence of hepatitis C virus (HCV) infection increases the risk of AKI development. However, the impact of HCV on AKI after LT has not been evaluated. The aim of this study was to assess the effect of HCV on AKI development in patients who underwent LT.

METHODS

Between January 2008 and April 2023, 2183 patients who underwent living donor LT (LDLT) were included. Patients were divided into 2 groups based on the presence of chronic HCV infection. We compared LT recipients using the propensity score matching (PSM) method. Factors associated with AKI development were evaluated using multiple logistic regression analysis. In addition, 1-year mortality and graft failure were assessed using a Cox proportional regression model.

RESULTS

Among 2183 patients, the incidence of AKI was 59.2%. After PSM, the patients with HCV showed a more frequent development of AKI (71.9% vs 63.9%, P = .026). In multivariate analysis after PSM, HCV was associated with AKI development (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.06-2.20, P = .022), 1-year mortality (Hazard ratio [HR], 1.98; 95% CI, 1.12-3.52, P = .019), and graft failure (HR, 2.12; 95% CI, 1.22-3.69, P = .008).

CONCLUSIONS

The presence of HCV was associated with increased risk for the development of AKI, 1-year mortality, and graft failure after LT.

Achieving 400 Living Donor Liver Transplantations Annually During the COVID-19 Pandemic: A Single-Center Experience

BACKGROUND

The COVID-19 pandemic has had a major impact on liver transplantation (LT) and living donor programs globally.

PURPOSE

In this study, we aimed to present the principles and strategies of our LT program during the pandemic period and describe its achievements.

BASIC PROCEDURES

We retrospectively reviewed the outcomes of 1417 LTs performed at Asan Medical Center, Seoul, Korea, from 2020 to 2022. Of these, 216 recipients who received transplants from deceased donors were excluded, and 1201 recipients who received transplants from 1268 live donors were included in the study, including 38 children <18 years old.

MAIN FINDINGS

Among the 1201 living donor LT (LDLT) recipients, the most common indication for LT was unresectable hepatocellular carcinoma (315/1163, 27.1%) in adults and biliary atresia (29/38, 76.3%) in pediatric recipients. Emergency LDLT was performed in 40 patients (3.3%). The median model of end-stage liver disease and pediatric end-stage liver disease scores were 13.9 ± 7.2 and 13.8 ± 7.1, respectively. In-hospital mortality of recipients was higher than usual at 2.2%, but the cause of death was not related to COVID-19 infection. Of the 1268 live donors who underwent hepatectomy for liver donation, 660 (52.1%) underwent hepatectomy using a minimally invasive approach. Although 17 (1.3%) live donors experienced major complications, there were no serious life-threatening complications and no mortality.

CONCLUSION

Even in a pandemic era, a team with well-established infection control protocols, patient-tailored surgical strategies, and thorough perioperative care can maintain LDLT at a similar quantitative and qualitative level as in a non-pandemic era.

Modified patch-conduit venoplasty for portal vein hypoplasia in pediatric liver transplantation

Background

Portal vein (PV) interposition can induce various PV-related complications, making more reliable techniques necessary. The present study describes the development of a modified patch venoplasty technique, combining the native PV wall and a vein homograft conduit, called modified patch-conduit venoplasty (MPCV).

Methods

The surgical technique for MPCV was optimized by simulation and applied to seven pediatric patients undergoing liver transplantation (LT) for biliary atresia combined with PV hypoplasia.

Results

The simulation study revealed that inserting the whole-length native PV wall as a longitudinal rectangular patch was more effective in preventing PV conduit stenosis than the conventional technique using triangular partial insertion. These findings were used to develop the MPCV technique, in which the native PV wall was converted into a long rectangular patch, acting as a backbone for PV reconstruction. A longitudinal incision on the vein conduit converted the cylindrical vein into a large vein patch. The wall of the native PV was fully preserved as the posterior wall of the PV conduit, thus preventing longitudinal redundancy and unwanted rotation of the reconstructed PV. This technique was applied to seven patients with biliary atresia undergoing living-donor and deceased-donor split LT. None of these patients has experienced PV complications for up to 12 months after transplantation.

Conclusions

This newly devised MCPV technique can replace conventional PV interposition. MCPV may be a surgical option for reliable PV reconstruction using fresh or cryopreserved vein homografts during pediatric LT.

WITHDRAWN: Multiple Swaps Tested: Rehearsal for Triple and Five-Liver Paired Exchanges

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Outcomes of the Initial Phase of an Adult Living vs Deceased Donor Liver Transplantation Program in a Low-Volume Transplant Center: Integration of Hepatobiliary and Transplant Surgery

BACKGROUND

The development of living donor liver transplantation (LDLT) is clinically challenging, especially in a low-volume transplant program. We evaluated the short-term outcomes of LDLT and deceased donor liver transplantation (DDLT) to demonstrate the feasibility of performing LDLT in a low-volume transplant and/or high-volume complex hepatobiliary surgery program during the initial phase.

MATERIAL AND METHODS

We conducted a retrospective study of LDLT and DDLT in Chiang Mai University Hospital from October 2014 to April 2020. Postoperative complications and 1-year survival were compared between the 2 groups.

RESULTS

Forty patients who underwent LT in our hospital were analyzed. There were 20 LDLT patients and 20 DDLT patients. The operative time and hospital stay were significantly longer in the LDLT group than in the DDLT group. The incidence of complications in both groups was comparable, except for biliary complications, which were higher in the LDLT group. Bile leakage, found in 3 patients (15%), is the most common complication in a donor. The 1-year survival rates of both groups were also comparable.

CONCLUSION

Even during the initial phase of the low-volume transplant program, LDLT and DDLT had comparable perioperative outcomes. Surgical expertise in complex hepatobiliary surgery is necessary to facilitate effective LDLT, potentially increasing case volumes and promoting program sustainability.

Treatment patterns for hepatocellular carcinoma in patients with Child-Pugh class B and their impact on survival: A Korean nationwide registry study

BACKGROUND AND AIMS

There are no established practice guidelines for treating hepatocellular carcinoma (HCC) in patients with Child-Turcotte-Pugh (CTP) class B liver function. To evaluate the impact of various initial treatment modalities on these patients, we conducted a nationwide registry study in Korea.

MATERIALS AND METHODS

Treatment patterns and overall survival (OS) of patients with HCC and CTP class B according to initial treatment modalities in each Barcelona Clinic Liver Cancer (BCLC) stage were analysed using data from the Korean Primary Liver Cancer Registry between 2008 and 2016. Initial treatment modalities were categorized as standard, alternative treatment and supportive care only, referring to the 2018 BCLC guidelines, irrespective of liver function.

RESULTS

Of the 2318 newly diagnosed Korean patients with HCC and CTP class B, 29.7%, 60.3% and 15.6% of patients in BCLC stages A, B and C, respectively, underwent standard treatment. Adjusted OS hazard ratios of alternative treatment referring to standard treatment were 1.55 (95% confidence interval [CI], 1.25-1.94; p < .001) in BCLC-A, 0.82 (95% CI, 0.43-1.56; p = .550) for curative alternative treatment, 1.89 (95% CI, 0.97-3.68; p = .059) for non-curative alternative treatment in BCLC-B, 0.40 (95% CI, 0.28-0.56; p < .001) for curative alternative treatment, 0.84 (95% CI, 0.69-1.02; p = .076) for non-curative alternative treatment for BCLC-C.

CONCLUSION

Regardless of BCLC stages, chemoembolization was conducted the most among patients with CTP class B. Treatment in line with the BCLC treatment algorithm resulted in favourable OS outcomes, except for those with BCLC stage C, as systemic therapy showed poor OS.

Usability of intraoperative cine-portogram during liver transplantation in young pediatric patients with biliary atresia

BACKGROUND

Pediatric patients with biliary atresia (BA) often present liver cirrhosis-associated portal hypertension and portal vein (PV) hypoplasia. For successful liver transplantation (LT), it is essential to maintain sufficient PV inflow through stenosis-free PV reconstruction with effective ligation of collateral veins. The aim of this study was to assess the clinical usability of intraoperative cine-portogram (IOCP) in young pediatric patients who underwent LT for BA.

METHODS

Medical records of pediatric patients younger than 10 years who underwent primary LT for BA from 2018 to 2020 were reviewed.

RESULTS

A total of 31 patients had undergone Kasai portoenterostomy soon after birth. Their median ages at Kasai portoenterostomy and LT were 1 and 11 months, respectively. Types of LT were living-donor LT in 13, deceased-donor split LT in 15, and deceased-donor whole LT in three patients. PV interposition using an iliac vein homograft was performed in 28 patients receiving partial liver grafts. Side-to-side PV unification venoplasty was performed in three patients undergoing whole LT. All patients underwent ligation of collateral veins. IOCP was performed in 6 (19.4%) patients. Four showed no or faint residual venous collaterals. Collateral vein embolization and endovascular stenting were performed in one patient each. PV insufficiency-free survival rate was 100% at 1 year and 93.8% at 3 years. All patients are currently alive with a median follow-up period of 23 months.

CONCLUSIONS

Intraoperative cine-portogram can be a useful method for identification and embolization of residual portosystemic collateral veins in young pediatric patients who undergo LT for biliary atresia.

Prevention of HBV Recurrence After Liver Transplant: Long-Term Results

BACKGROUND

Antiviral therapy with or without hepatitis B immune globulin (HBIG) is a common strategy for the prevention of hepatitis B virus (HBV) reinfection. But there is no consensus on management protocols, and long-term data are relatively rare on recurrence of HBV infection after liver transplantation using a nucleoside analogue and HBIG prophylaxis.

METHODS

We performed 56 liver transplants since June 2006. Among them, 32 liver recipients had liver cirrhosis associated with HBV, 9 with hepatocellular carcinoma (HCC), and 23 without HCC. Three operative mortalities, 3 deaths within 1 year related to infection, and 1 follow-up loss less than 1 year were excluded from analysis. We analyzed 25 liver transplants retrospectively. We prevented HBV reinfection with entecavir or tenofovir lifelong with 7 days of daily intravenous HBIG, 10,000 units, including operative day, and then once a week for the next 3 weeks, and then once a month for 1 year. Afterward, 4000 or 6000 units every 2 or 3 months were given to maintain patients' serum hepatitis B antibody titer >200 mIU/mL.

RESULTS

Mean follow-up period for HBV reinfection was 120.3 months. No patients have had reinfection.

CONCLUSIONS

Lifelong HBIG and nucleoside is an excellent prevention strategy for HBV reinfection after liver transplant.