Original Article ㅣ 2021-11-30 853 276

Analysis of nationwide volume of liver transplantation in Korea during 2020 shows no definitive decrease during COVID-19 outbreak

Yong-Kyu Chung¹ , Sung-Hwa Kang²

Ann Liver Transplant 2021; 1(2): 135-139

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Abstract : Background: Recent outbreak of Coronavirus disease 2019 (COVID-19) has discouraged organ donation. To determine its impact on liver transplantation (LT) at Korean transplant centers, it is necessary to analyze the incidence and type of LT in each center. Methods: The number of deceased donor LT (DDLT) and living donor LT (LDLT) operations performed during the year 2020 were analyzed using the Korean Network for Organ Sharing (KONOS) database. Results: During the 21-year period from 2000 to 2020, the total number of all deceased organ donors was 6,064 and 5,252 cases of DDLT were performed. The deceased donor and DDLT case numbers were 450 and 391, respectively, in the year 2019, and 478 and 395, respectively, in the year 2020 (p=0.284). The mean number of monthly DDLT was 32.6±5.7 in 2019 and 32.9±4.7 in 2020 (p=0.877). The case numbers of DDLT and LDLT in 2020 were 395 and 1,221, respectively. Forty-one centers performed both DDLT and LDLT, but five centers performed only DDLT and another 10 centers performed only LDLT. The five major LT centers performed 974 cases, which accounted for 60.3% of nation-wide LT volume in 2020, including 45.3% of DDLT and 65.1% of LDLT. Conclusion: The results of this study suggested that national activities of DDLT and LDLT remained stable in Korea in the year 2020, despite of the ongoing COVID-19 pandemic. Further follow-up studies are necessary to validate the results of this study.

Case Report ㅣ 2021-11-30 803 319

Portal vein interposition in living donor liver transplantation for a pediatric hepatoblastoma patient with portal vein tumor thrombosis

Jung-Man Namgoong¹ , Shin Hwang¹ , Gil-Chun Park¹ , Hyunhee Kwon¹ , Suhyeon Ha¹ , Kyung Mo Kim² , Seak Hee Oh²

Ann Liver Transplant 2021; 1(2): 180-186

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Abstract : Liver transplantation is accepted as an effective therapeutic option for unresectable hepatoblastoma. We present a pediatric case of hepatoblastoma patient with portal vein tumor thrombosis (PVTT) that occluded the main portal vein completely despite neoadjuvant chemotherapy. The patient was a 36-month-old 17-kg girl suffering from hepatoblastoma with PVTT, which was partially regressed by neoadjuvant chemotherapy. Viable PVTT remained after left hepatectomy and repetition of systemic chemotherapy due to partial treatment response. To remove the tumor completely, we performed living donor liver transplantation using her mother’s left lateral section graft. The blood flow from the native portal vein was greater than that from the pericholedochal collaterals, thus we used the native portal vein as the source of portal inflow. A cold-stored fresh external iliac vein homograft was anastomosed to the portal vein stump. Graft implantation was performed using standard procedures of pediatric liver transplantation. The patient recovered uneventfully. She has been undergoing scheduled adjuvant chemotherapy to date. Meticulous design for portal vein reconstruction using interposition vein graft with the remaining splanchnic vein stumps resulted in successful portal vein reconstruction with complete removal of PVTT.

Review Article ㅣ 2021-11-30 736 304

Impact of COVID-19 on the number of deceased donors and organ transplantation in Western countries

Cheon-Soo Park¹ , Yo-Han Park²

Ann Liver Transplant 2021; 1(2): 123-128

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Abstract : The severe acute respiratory syndrome coronavirus 2 disease 2019 (COVID-19) pandemic has an impact on all facets of our health care system, including life-saving procedures. The COVID-19 in 2020 has a substantial impact on the transplant community. This study aimed to assess the impact of COVID-19 on the number of deceased donors and organ transplantation in Western countries by analyzing literature review. In Spain, the COVID-19 pandemic has posed significant challenges to the Spanish donation and transplantation program. The program activities decreased substantially during the most critical weeks of the first COVID-19 wave, but recovered over the next weeks to return to a reasonable level. In France, there was a 28% decrease in the number of organ donations and a 22% decrease in the number of liver transplantation in 2020. In Italy, a 47% reduction in organ donation and a 44% reduction in transplantation during the first 6 weeks of the COVID-19 pandemic compared with one year before. In the United States of America, the overall reduction in deceased donor transplantations since the COVID-19 outbreak was 51.1%, with the highest percentage of reduction in kidney transplantation. The present study revealed that there is a strong association between the increase in COVID-19 infections and a striking reduction in solid organ transplantation procedures. However, further studies are necessary to follow up and validate the results of this study.

Review Article ㅣ 2021-11-30 693 1094

Liver transplantation in Wilson’s disease: A systematic review

Emre Turgut , Cemalettin Aydin , Cuneyt Kayaalp , Sezai Yilmaz

Ann Liver Transplant 2021; 1(2): 113-122

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Abstract : Wilson’s disease (WD) is a rare genetic disorder affecting the metabolism of copper that may present with neurological symptoms. In cases leading to hepatic failure, liver transplantation (LT) may be necessary. The aim of this paper is to examine the literature on LT cases related to WD in terms of disease characteristics, the neurological conditions of patients and survival rates. The keywords “Wilson and transplant*” were used to perform a title and abstract search across three databases (PubMed, Scopus, Web of Science) up until November 2018. The results from a total of 791 patients, mentioned in 28 studies, were analyzed. Thirty-nine point six percent of the patients received emergency LT and acute liver failure was more predominant in woman patients (61.7%-38.3%; p<0.0001). Live donations accounted for 36.6% of the transplants with none of these patients experiencing recurrence of disease. 36.4% of the patients displayed neurological symptoms prior to the transplant; however, following the operation these symptoms decreased by 74.2%. Survival rates for 1, 2, 3, 5, 10 years were 84%, 82%, 81%, 81%, and 80%, respectively. Further research into the reasons that acute liver failure in patients suffering from WD is more common among women is needed. Moreover, while mortality rates for up to one-year post-transplant are 16%, this rate is only 4% for the following 1–10 years. As neurological symptoms experienced prior to transplantation decrease by 74.2% after the operation, further studies should be carried out into the factors that determine potential neurological improvement.

Case Report ㅣ 2021-11-30 674 557

Magnetic compression anastomosis for treatment of post-transplant biliary stricture: A case report with dual-graft living donor liver transplantation

Dong-Hwan Jung¹ , Do Hyun Park² , Gi-Won Song¹ , Chul-Soo Ahn¹ , Deok-Bog Moon¹ , Shin Hwang¹

Ann Liver Transplant 2021; 1(2): 174-179

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Abstract : Radiological intervention via percutaneous transhepatic biliary drainage and endoscopic intervention via endoscopic retrograde cholangiopancreatography are the preferred methods to treat liver transplantation (LT)-associated benign biliary stricture (BBS). Magnetic compression anastomosis (MCA) can be applied to reconstruct a refractory or completely obstructing BBS that cannot be resolved with conventional methods. The MCA procedure is divided into four steps: tract formation for magnet delivery, approximation of magnets, removal of the approximated magnets, and maintenance and removal of the internal catheter. We present a patient with BBS, following dual-graft living-donor LT, which was successfully recanalized via MCA with detailed review of technical procedures. In the present case, MCA facilitated the passing of the guidewire through the completely occluded BBS for conventional treatment via long-term endobiliary stenting. MCA is a nonsurgical alternative for treating severe or completely obstructing BBSs that are refractory to conventional endoscopic or percutaneous treatment methods.

How-I-Do-It ㅣ 2021-11-30 656 238

Minimal-incision donor right hepatectomy for living donor liver transplantation

Tae-Yong Ha , Dong-Hwan Jung , Gi-Won Song , Gil-Chun Park , Shin Hwang

Ann Liver Transplant 2021; 1(2): 140-145

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Abstract : For living donors, the second most important concern after the donor safety is the cosmetic aspect of abdominal incision. The present study aimed to present the technical details of minimal-incision laparotomy (MIL) in a case of living donor right hepatectomy with an eight minutes video clip. The recipient was a 57-year-old patient with alcoholic liver cirrhosis and the donor was his 28-year-old daughter of the recipient. The epigastrium area was narrow and the subcostal cartilages were elongated beyond the level of the umbilicus, so a 12-cm-long right subcostal incision was made. The right liver was mobilized with gentle traction. The right hepatic parenchyma was transected according to standard procedures and liver-hanging with a Penrose drain. A 780 g-weighing right liver graft was harvested and pulled out through the skin incision. The liver graft was converted to a modified right liver graft with patch and conduit venoplasties of the outflow veins. Both the recipient and donor recovered uneventfully and have been doing well for 12 years after transplantation. We believe that MIL is a compromise option between conventional skin incision and total laparoscopic hepatectomy regarding cosmetics of the skin incision and donor safety, although it is a demanding procedure for donor surgeons.

Case Report ㅣ 2021-11-30 650 311

Fifteen-year-long journey with hepatocellular carcinoma from diagnosis during pregnancy to recurrence after liver transplantation: A case report of intractable tumor recurrence

Shin Hwang , Dong-Hwang Jung , Tae-Yong Ha

Ann Liver Transplant 2021; 1(2): 194-201

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Abstract : Hepatocellular carcinoma (HCC) during pregnancy is very rare and reported to be associated with inferior prognosis. We herein present a case of a patient who was diagnosed with HCC at the age of 26 years during pregnancy. The patient was infected with hepatitis B virus through vertical transmission. After full-term vaginal delivery, the patient underwent transarterial chemoembolization (TACE) twice and right hepatectomy consecutively. One year later, TACE was repeated and second hepatectomy was performed. Four years later, TACE was repeated and third hepatectomy was performed. Two years later, TACE was repeated and fourth hepatectomy was performed. Two years later, HCC recurred around the left hepatic duct and external beam radiotherapy was performed. Subsequently, biliary stenosis occurred, thus endoscopic retrograde biliary drainage tube was inserted. One year later, her liver function deteriorated with tumor progression and portal vein occlusion. The patient underwent deceased donor liver transplantation using an HBsAg-positive whole liver graft. At posttransplant 6 months, pulmonary metastasis occurred, which was managed with pulmonary metastasectomy twice and radiotherapy. The patient passed away 20 months after transplantation because of HCC progression. The patient had suffered from HCC for 15 years, in which she underwent hepatectomy four times, TACE 10 times, liver transplantation, pulmonary metastasectomy twice, and radiotherapy three times. The patient demonstrated unusual long-term intractable course of HCC recurrence refractory to various locoregional treatments.

How-I-Do-It ㅣ 2021-11-30 624 308

Application of a tissue expander to stabilize graft position in liver transplantation

Woo-Hyoung Kang , Shin Hwang , Chul-Soo Ahn , Deok-Bog Moon , Tae-Yong Ha , Gi-Won Song , Dong-Hwan Jung , Gil-Chun Park , Jung-Man Namgoong , Yong-In Yoon , Sung-Gyu Lee

Ann Liver Transplant 2021; 1(2): 146-152

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Abstract : A small-sized left liver graft may fall into the large right subphrenic fossa, in which such a size mismatch can result in graft hepatic vein outflow obstruction as well as excessive stretching of the reconstructed portal vein. A tissue expander (TE) was used to prevent detrimental dextro-rotation of the liver graft through obliteration of the dead space at the right subphrenic fossa. We herein present our experience regarding TE application in liver transplantation (LT). TEs of various sizes and shapes are commercially available, and the dome-shape TEs with an external connecting tube and an injection port are the most frequently used. The indications for TE application can be classified into four categories: pediatric LT cases using a living-donor or split deceased-donor left-sided liver graft, adult LT cases using a living-donor left liver graft, LT with dual-graft implantation, and unusual conditions such as a recipient with situs inversus. The underlying cause of TE application is basically identical in all four categories, but the technical details of TE application differ from each other. The timing of TE removal depends on the degree of graft regeneration and the amount of water within the TE, which is usually 1 to 3 weeks after LT. We experienced no serious adverse TE-associated complications in more than 100 cases. In conclusion, TE application is simple, safe, and effective to provide mechanical support for the liver graft, and therefore performed readily if indicated.

How-I-Do-It ㅣ 2021-11-30 623 238

Technical refinement of inferior vena cava replacement using a synthetic vascular graft in living donor liver transplantation

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

Ann Liver Transplant 2021; 1(2): 153-159

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Abstract : The native inferior vena cava (IVC) can be resected during living donor liver transplantation (LDLT) in Budd-Chiari syndrome or advanced hepatocellular carcinoma (HCC). The present study aimed to present the technical details of IVC replacement with synthetic vascular graft interposition. Following laparotomy, the recipient liver was mobilized to expose the IVC. Piggyback or classical total hepatectomy including IVC was performed. In patients with Budd-Chiari syndrome, atrio-caval anastomosis with a vascular graft is necessary, in which clamp slippage should be completely prevented. No-touch en bloc isolation of the native liver is necessary for patients with advanced HCC. The wall of a large-caliber vascular graft is pleated to prevent luminal collapse, suggesting the need for tension to stretch it. The length of a vascular graft should be adjusted meticulously. An adequately interposed vascular graft appears to be rather short under IVC cross-clamping, but elongated and expanded after restoration of the IVC flow. A single right or left liver graft, or even dual-graft can be implanted to the interposed IVC vascular graft. An elliptical excision of the graft wall is mandatory for graft hepatic vein implantation, because an incision at the graft does not expand. In conclusion, IVC replacement with interposition of a synthetic vascular graft expands the indications for LDLT, particularly in patients with Budd-Chiari syndrome and advanced HCC, similar to those of deceased donor liver transplantation.

Case Report ㅣ 2021-11-30 607 286

Pancreaticoduodenectomy for de novo ampulla of Vater cancer 15 years after living donor liver transplantation: Report of a case

Byeong-Gon Na , Shin Hwang , Sung-Min Kim , Geunhyeok Yang

Ann Liver Transplant 2021; 1(2): 187-193

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Abstract : De novo malignancy sporadically occurs in patients who undergo liver transplantation. We present a case of a 74-year-old patient who underwent pancreaticoduodenectomy (PD) for de novo ampulla of Vater cancer at 15 years after living donor liver transplantation (LDLT) for hepatitis B virus-associated liver cirrhosis. At 15 years after LDLT, elevation of liver enzyme levels led to diagnosis of de novo ampulla of Vater mass. We performed pylorus-resecting PD with extended pancreatic transection. Roux-en-Y choledochojejunostomy was performed to the remnant recipient-side proximal bile duct because active back bleeding from the bile duct stump was identified. The patient recovered uneventfully without complications. The surgical specimen showed a 2 cm-sized moderately differentiated adenocarcinoma arising from a tubular adenoma of the intestinal subtype at the ampulla of Vater. The extent of the tumor was pT1bN0M0, thus being stage IB. Adjuvant chemotherapy was not performed. The patient has been doing well for 3 months. The immunosuppressive regimen was switched from mycophenolate mofetil monotherapy to everolimus monotherapy. Our experience with this case suggests that PD can be eligibly performed after LDLT using duct-to-duct anastomosis.