Original Article ㅣ 2021-05-31 295 140

Absence of influence of the Korean MELD score-based liver allocation system on pretransplant MELD score in patients undergoing living donor liver transplantation

Sang Hoon Kim , Shin Hwang , Chul-Soo Ahn , Deok-Bog Moon , Tae-Yong Ha , Gi-Won Song , Dong-Hwan Jung , Gil-Chun Park , Ki-Hun Kim , Young-In Yoon , Woo-Hyoung Kang , Hwui-Dong Cho , Minjae Kim , Byeong-Gon Na , Sung-Min Kim , Geunhyeok Yang , Sung-Gyu Lee

Ann Liver Transplant 2021; 1(1): 10-17

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Abstract : Background: Model for end-stage liver disease (MELD) score-based allocation system was started in 2016 in Korea. This study aimed to analyze the profiles of adult patients who underwent living donor liver transplantation (LDLT) in the pre- and post-MELD eras. Methods: This study was a retrospective double-arm analysis using a single-institution LDLT cohort. We compared the LDLT recipient profiles by focusing on pretransplant MELD score for 4 years before and after the introduction of the MELD scorebased allocation system. Patients without and with hepatocellular carcinoma (HCC) were categorized as Group A and B in the pre-MELD era and Group C and D in the post-MELD era, respectively. Results: The number of patients in Groups A, B, C and D was 615, 599, 704 and 713, respectively; and their MELD scores were 19.0±9.4, 11.2±5.6, 17.9±8.5 and 11.6±5.7, respectively. Clinical parameters of liver cirrhosis indicate that Group A had worse general conditions than Group C; and Groups B and D had similar general conditions. The comparative analysis between Groups A and C revealed the mean and median MELD scores as 19.0±9.4 and 17.9±8.5 (p=0.009), and 16 and 15 (p=0.077), respectively. The comparative analysis between Groups B and D revealed the mean and median MELD scores as 11.2±5.6 and 11.6±5.7 (p=0.14), and 9 and 9 (p=0.14), respectively. Conclusion: Median pretransplant MELD score was in the range of 15-16 in LDLT recipients without HCC and 9 in those with HCC. Introduction of MELD score in deceased donor organ allocation system resulted in a marginal decrease in the pretransplant MELD score in patients undergoing LDLT without HCC, but no change in those with HCC.

Review Article ㅣ 2021-05-31 219 214

Tailored standardization of portal vein reconstruction for pediatric liver transplantation at Asan Medical Center

Shin Hwang , Jung-Man Namgoong

Ann Liver Transplant 2021; 1(1): 71-78

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Abstract : Pediatric recipients, especially infants, are vulnerable to vascular complications because recipient vessels are smaller than those in adult liver transplantation (LT). Once portal vein (PV) stenosis occurs, it is often difficult to treat it through radiological angioplasty. Endovascular stenting is regarded as the final life-saving procedure, with a likelihood of needing retransplantation later. We have established standardized customization of surgical techniques for pediatric LT. Here, we present our tailored standardization of PV reconstruction for pediatric LT with the following 5 topics. 1) tadpole vein homograft conduit interposition for hypoplastic PV in infant patients undergoing split or living donor LT; 2) side-to-side anastomosis for hypoplastic PV in infant patients undergoing infant-to-infant whole liver LT; 3) PV branch patch venoplasty for size-matching in pediatric patients undergoing split or living donor liver transplantation; 4) PV conduit interposition in pediatric patients with congenital absence of PV; 5) wedged patch venoplasty for small-sized graft left PV. There are two features in our techniques for PV reconstruction: 1) frequent use of vein homograft; and 2) funneling of the recipient PV to match with the graft PV. In conclusion, secure PV reconstruction is important for successful pediatric LT. Thus, every effort should be made to ensure obtainment of sufficient portal blood inflow. From the viewpoint of hemodynamics principles, a funnel-shaped PV conduit is the most desirable configuration to ensure effective flow from the splanchnic system in infant patients with PV hypoplasia.

Review Article ㅣ 2021-05-31 190 124

Selection criteria of living donor liver transplantation for hepatocellular carcinoma developed in Korean transplant centers

Dong-Hwan Jung , Shin Hwang , Gi-Won Song

Ann Liver Transplant 2021; 1(1): 29-47

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Abstract : With accumulated experience on living donor liver transplantation (LDLT) for hepatocellular carcinoma (HCC), several major Korean transplant centers presented institutional or multicenter selection criteria of LDLT for HCC based on their own experience. This study intended to review the selection criteria of LDLT for HCC developed in the major Korean LT centers. Extended criteria for primary liver transplantation (LT) were developed in Asan Medical Center (AMC) in 2008, the Catholic University of Korea in 2012, Samsung Medical Center in 2014, National Cancer Center Korea in 2016, the model to predict tumor recurrence after LDLT (MoRAL) in three centers in 2016, A-P 200 criteria in Pusan National University in 2016, patient selection by tumor markers in LT for advanced HCC in eight centers, composite criteria using clinical and PET factors in two centers in 2019, tumor size and number, AFP, PIVKA-II, PET (SNAPP) score in AMC in 2021, and quantitative prognostic prediction using AFP-PIVKA-II-tumor volume (ADV) score in AMC in 2021. The criteria for salvage LT were developed from a multicenter study involving three centers in 2014 and from AMC in 2020. Posttransplant prognostic prediction models for early or non-viable HCC were developed in AMC for super-selection criteria in 2011 and pretransplant treatment-induced complete tumor necrosis in 2017. The importance of tumor biology in HCC treatment has been emphasized more than before. The expression of serum tumor markers is a surrogate biomarker reflecting the tumor biology. Pretransplant radiological assessment of HCC combined with tumor marker expression or PET finding will provide reliable information that will assist the decision to perform LDLT in patients with HCC of various stages.

Original Article ㅣ 2021-05-31 185 139

Prognostic impact of MELD scores greater than 40 in deceased donor liver transplant recipients

Byeong-Gon Na , Shin Hwang , Gil-Chun Park , Gi-Won Song , Dong-Hwan Jung , Tae-Yong Ha , Chul-Soo Ahn , Deok-Bog Moon , Ki-Hun Kim , Young-In Yoon , Woo-Hyoung Kang , Hwui-Dong Cho , Minjae Kim , Sang Hoon Kim , Sung-Gyu Lee

Ann Liver Transplant 2021; 1(1): 2-9

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Abstract : Background: Since 2016, Korean liver organ allocation system has been based on model for end-stage liver disease (MELD). Some patients on waiting list progressed to MELDs >40 due to serious shortage of donor organs. This study investigated prognosis of deceased donor liver transplantation (DDLT) recipients with MELD scores >40. Methods: Data from adult patients with MELD scores ≥31 who underwent DDLT between June 2016 and November 2019 were retrospectively evaluated. Patients were categorized according to Korean Network for Organ Sharing (KONOS) status 3, 2, or MELD-over-40. Results: During the study period, 168 DDLT operations were performed in 160 patients with KONOS status 3 in 77 (48.1%), status 2 in 65 (40.6%) and MELD-over-40 in 18 (11.3%). Graft survival rates of primary DDLT were 84.0% at 1 year and 70.7% at 3 years. Overall patient survival was 85.2% at 1 year and 70.7% at 3 years. The 3-year patient survival was 74.4%, 75.7%, and 52.7% in KONOS status 3, status 2, and MELD-over-40 groups (p=0.19). Pretransplant ventilator support was associated with inferior patient survival outcomes (p=0.043), but pretransplant renal replacement therapy showed no prognostic significance. Retransplantation showed a significant prognostic difference (p<0.001). Multivariate analysis for overall patient survival showed that pretransplant ventilator support and retransplantation were significant prognostic factors, but MELD score >40 was not seen to be an independent risk factor. Conclusion: This analysis revealed that very high MELD scores >40 appear to confer additional risk in patients with KONOS status 2 although it was not an independent prognostic factor.

How-I-Do-It ㅣ 2021-05-31 180 136

Quilt unification venoplasty of the right hepatic veins enabling double inferior vena cava anastomosis in living donor liver transplantation using a right liver graft

Dong-Hwan Jung , Shin Hwang , Chul-Soo Ahn , Deok-Bog Moon , Tae-Yong Ha , Gi-Won Song , Gil-Chun Park , Byeong-Gon Na , Sung-Gyu Lee

Ann Liver Transplant 2021; 1(1): 86-94

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Abstract : The inferior right hepatic veins (IRHVs) and major short hepatic veins (SHVs) are indicated for vascular reconstruction to prevent hepatic venous congestion of the right liver grafts. As separate anastomoses of multiple IRHV/SHVs are vulnerable to stenosis, single large anastomosis through the unification of multiple hepatic vein openings is preferred. All right hepatic vein (RHV) openings can be unified through quilt unification venoplasty (QUV). After the introduction of QUV in 2004, we have developed several techniques and institutional guidelines for QUV. There are two types of QUV, all-in-one and RHV types. All-in-one QUV unifies the orthodox RHV, IRHV, SHV, and middle hepatic vein (MHV) branches using a large patch and MHV conduit. QUV for RHVs unifies the orthodox RHV, IRHV, and SHV, with separate reconstruction of the MHV conduit because a conjoined MHV conduit can be associated with outflow problems. For side-to-side anastomosis of QUV as like the double vena cava reconstruction, deep side-clamping of the recipient inferior vena cava is usually performed; however, shallow partial clamping can be used if necessary. The anatomy of the donor liver SHVs and the availability of sizable vessel patches are the primary determinants for designing the individualized configuration of QUV. We suggest that QUV using various vessel patches is useful for secure reconstruction of multiple IRHVs and SHVs to achieve successful implantation of the right liver grafts.

Review Article ㅣ 2021-05-31 176 69

Current vascular allograft procurement, cryopreservation and transplantation techniques in the Asan Medical Center Tissue Bank

Shin Hwang^1,2,3 , Ju Hee Bae^2,3 , In-Ok Kim^2,3 , Jung-Ja Hong²

Ann Liver Transplant 2021; 1(1): 79-85

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Abstract : Vascular allografts are important materials to facilitate partial liver graft reconstruction in living donor liver transplantation (LDLT). Tissue banks are essential in providing vascular allografts used in LDLT. This study is intended to present the details of vascular allograft procurement, cryopreservation, and transplantation techniques, which are currently used in the Asan Medical Center Tissue Bank according to the standard operating procedure (SOP). Vascular allografts can be procured from the deceased organ donors or tissue donors. In practice, the majority of vessel donors are deceased multiorgan donors, thus the vessel grafts are harvested following multiorgan donation. The vascular allografts are cryopreserved according to the SOP and stored at —150°C in the vapor phase of liquid nitrogen. They can be kept for 10 years at the tissue bank. For clinical use, the cryopreserved vessel grafts are melted rapidly. At our institution, the majority of cryopreserved vascular allografts have been used for LDLT operations and some of them are also used for various hepatobiliary and vascular surgeries. In conclusion, the supply of vascular allografts through cryopreservation at the institutional tissue bank is an essential preparation to facilitate adult LDLT operations requiring various vascular reconstruction that use patches or conduits.

Review Article ㅣ 2021-05-31 160 114

Tailored techniques of graft outflow vein reconstruction in pediatric liver transplantation at Asan Medical Center

Shin Hwang , Jung-Man Namgoong

Ann Liver Transplant 2021; 1(1): 58-70

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Abstract : Pediatric recipients are vulnerable to vascular complications because recipient vessels are small. Once graft outflow vein stenosis occurs, it is difficult to treat it effectively. To minimize the risk of hepatic vein outflow obstruction, it is necessary to perform individually designed reconstruction customized to each pediatric liver transplantation (LT) operation. We present our tailored surgical techniques for hepatic vein reconstruction in pediatric LT with the following five topics. 1) recipient hepatic vein unification venoplasty for implantation of left liver and left lateral section grafts; 2) graft hepatic vein venoplasty for left lateral section grafts; 3) graft hepatic vein venoplasty for left lateral section grafts with anomalous left hepatic vein anatomy; 4) graft hepatic vein unification venoplasty for left liver grafts; 5) inferior vena cava replacement during pediatric living donor liver transplantation; and 6) modified piggyback anastomosis of the graft inferior vena cava in infant-to-infant whole liver transplantation. There are three features in our techniques for graft hepatic vein reconstruction, including maximal usage of the recipient hepatic vein stumps, maximal widening of the graft outflow vein orifice through unification and patch venoplasty, and frequent use of vein homografts. In conclusion, secure graft outflow vein reconstruction is the most important step for successful pediatric LT. Thus, every effort should be done to minimize the risk of hepatic vein outflow obstruction. We strongly suggest that the diameter of graft hepatic vein anastomosis should be made as large as possible regardless of recipient age and body size.

Review Article ㅣ 2021-05-31 155 84

Living donor liver transplantation-associated retransplantation in adult patients

Deok-Bog Moon , Shin Hwang , Chul-Soo Ahn , Tae-Yong Ha , Gi-Won Song , Dong-Hwang Jung , Gil-Chun Park

Ann Liver Transplant 2021; 1(1): 48-57

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Abstract : Adult-to-adult living donor liver transplantation (LDLT) has been established as a successful alternative to help solve the serious shortage problem of deceased donor (DD) grafts. LDLT-associated retransplantation has been much less frequently performed than DD liver transplantation-associated retransplantation due to lower incidence of primary nonfunction, advance in surgical technique for LDLT, and organ shortage for retransplantation. Common causes of retransplantation include immunologic rejection, primary nonfunction or severe dysfunction, biliary complications, recurrence of primary disease and vascular complications. LD-associated retransplantation can be classified into three types according to the sequences of the grafts used: LD-to-LD, LD-to-DD, and DD-to-LD because different surgical techniques should be considered according to the different sequences. They are also re-classified into two types according to the retransplantation timing: early and late. The most typical type of LDLT-associated retransplantation is early LD-to-DD retransplantation. Any cause of early graft failure can be indicated for this type of retransplantation if a DD organ is available. For early LD-to-LD retransplantation, the type of second liver graft and hepatic arterial inflow source should be considered prudently. Early DD-to-LD retransplantation has been usually applied to primary non-function of the first DD liver graft. Late LD-to-LD or DD-to-LD retransplantation is not recommended because of heavy adhesion and anatomical distortion. The outcome of LDLT-associated retransplantation appears to be inferior to that of DDto- DD retransplantation. There are several technical limitations. Procurement of a LD liver graft with long vascular stumps is not allowed. Thus, alternative methods of vascular reconstruction are often required, which have high technical difficulty. Furthermore, the timing of retransplantation is usually suboptimal, given the shortage of DD and LD grafts and the urgency involved with the failing first liver graft. Fundamental requirements for improving retransplantation results include expanding the donor pool and having a proper timing of retransplantation.

Original Article ㅣ 2021-05-31 155 99

Risk factors for alcohol recidivism after liver transplantation

Hyeok Jun Yun¹ , Jae Geun Lee^1,2 , Hyun Jeong Kim¹ , Dai Hoon Han¹ , Gi Hong Choi¹ , Myoung Soo Kim^1,2 , Jin Sub Choi^1,2 , Soon Il Kim^1,2 , Dong Jin Joo^1,2

Ann Liver Transplant 2021; 1(1): 18-23

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Abstract : Background: Alcoholic liver disease (ALD) has been increasing recently and the second most common indication for liver transplantation (LT) in Korea. Even after LT, alcohol recidivism can be a problem interfering with the patients’ long-term survival and graft function. This study was conducted to analyze the clinical course and preand post-transplantation risk factors for alcohol recidivism in transplant recipients with ALD. Methods: Of 592 liver transplant recipients, sixty-two patients underwent LT for ALD between Jan 2005 and Dec 2014. We retrospectively collected and analyzed the data from our electrical medical records. Results: Out of the 62 ALD recipients, 57 patients were male. Their mean age was 52.4±8.3 years. The mean abstinence period of them before transplantation was 17.7±30.0 months. Sixteen recipients (25.8%) showed alcohol recidivism at 15.9±13.7 months after LT. Patients who showed alcohol recidivism had a significantly longer duration of drink before transplantation than non-recidivism patients (35.4±6.3 vs 30.9±9.4 years, respectively, p=0.038). In terms of alcohol consumption, the recidivism group showed more alcohol drinking than the non-recidivism group (123.0±67.2 vs 81.6±61.0 units, respectively, p=0.026). The abstinence period before LT was not significantly different. In the multivariate analysis, the amount of alcohol consumption before transplantation was considered to play a risk factor for alcohol recidivism after transplantation (p=0.05). Conclusion: Information about duration and consumption of alcohol drink before LT helps to predict alcohol recidivism after LT in patients with ALD, allowing early awareness and specific postoperative care.