Review Article

De novo gastric cancer after liver transplantation: A review of the Asian experience

Cheon-Soo Park¹ , Yong-Kyu Chung²

Ann Liver Transplant 2023; 3(1): 1-5

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Abstract : While the long-term survival outcome following liver transplantation (LT) has improved, hepatocellular carcinoma recurrence and de novo malignancy remain the major causes of patient death. Gastric cancer is one of the most frequent malignancies in Asian countries, thus this study reviewed the incidence of de novo gastric cancer following LT in Asian countries. Four Korean single-center studies revealed that de novo gastric cancer is the most common de novo malignancy after LT. The standard incidence ratio of gastric cancer in LT recipients was 1,036 per 100,000 persons in males and 318.9 per 100,000 in females. Annual or biannual endoscopic screening for gastric cancer after LT is recommended. Open gastrectomy was the standard procedure, and endoscopic resection and laparoscopic surgery were also performed. A Japanese national survey revealed that de novo gastric cancer was the third common malignancy after organ transplantation. Two Chinese studies also revealed that de novo gastric cancer was one of the common de novo malignancies after organ transplantation. In conclusion, LT recipients should be checked periodically for de novo malignancy throughout their lives, especially for cancers common in the general population. Aggressive surgical treatment contributes to the improvement of post-treatment survival outcomes.

Review Article

Liver transplantation for hepatic epithelioid hemangioendothelioma: A review of European and Korean experience

Jeong-Ik Park¹ , Bo Hyun Jung²

Ann Liver Transplant 2023; 3(1): 6-10

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Abstract : Indications for liver transplantation (LT) are gradually expanding with the introduction of outcomes that act as benchmarks for the efficacy of newer indications. This review intended to summarize the current evidence in LT for hepatic epithelioid hemangioendothelioma (HEHE). Despite the limited worldwide experience with LT due to the global rarity of HEHE, the reported outcomes have generally been favorable. A European collaborative study presented the results of the second HEHE-European Liver Transplant Registry study, which showed overall posttransplant recurrence rate of 24.8% and 5-year disease-free survival rate of 79.4%. This study identified three risk factors for disease recurrence: short pretransplant waiting time of less than 120 days, macrovascular invasion, and hilar lymph node involvement. A Korean single-center study presented the outcomes in four patients with HEHE who underwent living donor liver transplantation from 2007 to 2016. All patients were preoperatively diagnosed with HEHE. The tumors were multiple and scattered over the entire liver, precluding liver resection. The mean model for end-stage liver disease score was 10.8±5.7. All patients underwent living donor LT using modified right liver grafts, with a graft-to-recipient weight ratio of 1.11±0.19. All patients recovered uneventfully after LT, resulting in 5-year disease-free and overall patient survival rates of 75% each. In conclusion, LT can be considered as an effective treatment for patients with unresectable HEHE that is confined within the liver and with acceptable risk factors.

Original Article

Outcomes of pure laparoscopic donor hepatectomy for a right lobe graft weighing more than 1,000 g

Suk Kyun Hong , Minseob Kim , Youngjin Kim , Jaeyoon Kim , Hyun Hwa Choi , Jaewon Lee , Jiyoung Kim , Su young Hong , Jeong-Moo Lee , YoungRok Choi , Nam-Joon Yi , Kwang-Woong Lee , Kyung-Suk Suh

Ann Liver Transplant 2023; 3(1): 11-16

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Abstract : Background: Minimally invasive hepatectomy has gained popularity in donor hepatectomy for living-donor liver transplantation. Guidelines suggest that pure laparoscopic donor hepatectomy should be considered a standard practice for experienced surgical teams. Pure laparoscopic donor right hepatectomy (PLDRH) is performed in selected cases. High graft weight has been reported to be an important factor in the selection process. This study aimed to determine whether it is safe and feasible to use PLDRH on large liver grafts weighing >1,000 g by analyzing multiple cases. Methods: We retrospectively reviewed the medical records of PLDRH cases in which the graft weight exceeded 1,000 g between November 2015 and December 2021. Results: Twenty cases of PLDRH were identified in which the graft weight exceeded 1,000 g. The median operative time, time to liver removal, and estimated blood loss were 322.5 minutes, 229.0 minutes, and 325.0 mL, respectively. There was a slight trend towards a decreased total operative time as the number of cases increased. The warm ischemic time significantly decreased as the number of cases increased. The median duration of hospital stay for donors was 7.0 days, and only two cases each of grade I and grade II complications were reported. No complications rated as grade III or higher were observed. Conclusion: PLDRH on large liver grafts weighing over 1,000 g is feasible and safe for experienced surgical teams, as it shows good postoperative outcomes with no major complications.

Case Report

Rescue therapy using transjugular intrahepatic portosystemic shunt for sudden-onset portal vein thrombosis-associated ascites after living donor liver transplantation

Geunhyeok Yang¹ , Shin Hwang² , Gi-Young Ko³ , Gi-Won Song² , Deok-Bog Moon² , Dong-Hwan Jung² , Chul-Soo Ahn² , Tae-Yong Ha² , Gil-Chun Park²

Ann Liver Transplant 2023; 3(1): 17-22

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Abstract : Sudden-onset portal vein (PV) thrombosis can result in refractory massive ascites. Transjugular intrahepatic portosystemic shunt (TIPS) can be a bridge or rescue therapy for the restoration of portal blood flow and control of ascites. We present one case of a liver transplant recipient who underwent TIPS as a rescue therapy to control PV thrombosis-associated refractory ascites. The patient who had received living donor liver transplantation 15 years before had PV thrombosis, which resulted in sudden-onset massive ascites. TIPS was performed to control refractory ascites. Soon after TIPS, the amount of ascites decreased rapidly, and the patient was discharged at 3 weeks after TIPS. Anticoagulation was maintained to prevent thrombus formation. Liver function was maintained well after TIPS, but the patient suffered from several episodes of hepatic encephalopathy. At 6 months after TIPS, stent flow was well maintained with stable liver function. Retransplantation was planned for the patient. In conclusion, the present case suggests that TIPS can be used as a rescue therapy for refractory ascites in liver transplant recipients with graft failure-associated portal vein thrombosis.

Case Report

Seven-year survival after peritoneal metastasis of hepatocellular carcinoma occurring 12 years after living donor liver transplantation

Min-Jae Kim¹ , Shin Hwang¹ , Gi-Won Song² , Deok-Bog Moon² , Dong-Hwan Jung² , Chul-Soo Ahn² , Tae-Yong Ha² , Gil-Chun Park²

Ann Liver Transplant 2023; 3(1): 23-28

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Abstract : Very late recurrence of hepatocellular carcinoma (HCC) after liver transplantation is rare. We herein present a case of peritoneal metastasis of HCC occurring 12 years after living-donor LT (LDLT), and surviving 7 years after HCC recurrence. A 65-year-old male patient who had undergone LDLT 12 years earlier showed marginally elevated tumor marker levels on regular outpatient follow-up. After observation for 3 months, follow-up studies revealed a peritoneal seeding mass. Thorough imaging studies revealed that the mass was highly likely to be metastatic HCC. Two mass lesions were excised, and the patient was administered low-dose calcineurin inhibitor, sirolimus, and full-dose sorafenib. Subsequently, the tumor marker levels increased again and growth of new peritoneal seeding nodules was observed; therefore, sorafenib was stopped after 2 years of administration. Immunosuppressive regimen was switched to everolimus monotherapy. During 7 years after HCC recurrence, the patient had experienced very slow progression of recurrent HCC, permitting good maintenance of quality of life. He died from far advanced HCC at the age of 72 years, at 19 years after LDLT. For very late peritoneal metastasis of HCC, aggressive multi-modality therapeutic treatment appears to be effective to prolong overall patient survival.

Case Report

Endovascular stenting for late-onset stricture of interposed portal vein conduit following pediatric liver transplantation

Jung-Man Namgoong¹ , Shin Hwang¹ , Gi-Young Ko² , Gil-Chun Park¹ , Kyung Mo Kim³ , Seak Hee Oh³

Ann Liver Transplant 2023; 3(1): 29-34

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Abstract : Portal vein (PV) interposition using a vein homograft can induce various PV complications. We present a case of pediatric living-donor liver transplantation (LDLT) showing late-onset stenosis of the interposed PV conduit, which was treated by endovascular stenting. The patient was an 11-month-old female infant weighing 7.8 kg with hepatoblastoma. She was partially responsive to systemic chemotherapy. Thus, LDLT was performed to treat the tumor. The living donor was the 34-year-old mother of the patient. After non-anatomical size reduction, the weight of the reduced left lateral section graft was 235 g, with a graft-to-recipient weight ratio of 3.0%. Recipient hepatectomy was performed according to the standard procedures of pediatric LDLT. The graft PV was anastomosed with an interposed external iliac vein homograft. The liver graft was partially accommodated in the right subphrenic fossa, resulting in dextro-plantation. The patient recovered from LDLT operation. However, at 4 months after transplantation, PV conduit stenosis occurred. This PV stenosis was initially treated with balloon dilatation, but the stenosis did not disappear. Finally, endovascular stenting was performed. The patient has been doing well for 3 years 6 months after transplantation with patent PV flow. In conclusion, inter-position of PV conduit carries risk of PV conduit stenosis, hence it is necessary to perform regular follow-up studies for PV patency for a prolonged period. Radiological intervention is the only therapeutic treatment for such PV conduit stenosis.

Case Report

Living donor liver transplantation with graft dextro-rotation and vein interposition in a pediatric patient with congenital absence of the portal vein

Jung-Man Namgoong¹ , Shin Hwang¹ , Gil-Chun Park¹ , Sang-Hoon Kim¹ , Kyung Mo Kim² , Seak Hee Oh²

Ann Liver Transplant 2023; 3(1): 35-43

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Abstract : Congenital absence of the portal vein (CAPV) is a rare venous malformation in which the mesenteric venous blood drains directly into the systemic circulation. We report a case of pediatric living donor liver transplantation (LDLT) for CAPV with a large portocaval shunt (PCS). A 10-year-old boy was diagnosed with CAPV at the age of 9 years. Multiple liver nodules and hepatopulmonary syndrome were progressed, therefore, we decided to perform LDLT. The graft was a left liver graft from the 45-year-old father of the patient. The recipient hepatectomy was performed according to the standard procedures of pediatric LDLT with isolation of a PCS vein. Unification venoplasty for graft outflow vein orifice was performed because of segment VIII vein at the donor liver. Iliac vein interposition was performed for portal vein extension. Graft dextro-rotation and portal vein interposition were used for anatomy-compliant vascular reconstruction. The patient recovered from the LDLT operation. The reconstructed graft hepatic vein and portal vein were maintained well without hemodynamic abnormality. This patient has been doing well for 2 months after the LDLT. In conclusion, since CAPV patients show various types of PCS, individualized portal vein reconstruction should be performed after thorough anatomical assessment before and during the liver transplantation operation.

Case Report

Modified left liver graft with funneling venoplasty of middle hepatic vein branches for pediatric living donor liver transplantation

Jung-Man Namgoong¹ , Gil-Chun Park¹ , Shin Hwang¹ , Sang-Hoon Kim¹ , Suhyeon Ha¹ , Kyung Mo Kim² , Seak Hee Oh²

Ann Liver Transplant 2023; 3(1): 44-49

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Abstract : We present a case of funneling venoplasty of middle hepatic vein (MHV) branch-preserving left liver (LL) graft in a pediatric patient undergoing living donor liver transplantation (LDLT). The recipient was a 31-month-old girl who was diagnosed with biliary atresia. The patient underwent Kasai portoenterostomy. However, her liver function deteriorated progressively. Thus, we decided to perform LDLT at a body weight of 15 kg. The donor was the 41-year-old mother of the patient. To protect the donor’s remnant liver from excessive hepatic venous congestion (HVC), we recovered an LL graft with preservation of the large segment VIII vein branch. There were three separate outflow veins at the graft liver cut surface, which were unified an iliac vein conduit. Funneling unification bench work resulted in a 3 cm-sized single outflow vein orifice. Standard procedures of pediatric LDLT were performed. Early follow-up computed tomography scans showed no vascular complications with patent graft outflow veins and no HVC at the remnant donor right liver. The patient has been doing well for three months after transplantation. This case suggests that our surgical technique using customized funneling venoplasty could enable successful reconstruction of MHV branches at the LL graft. Our experience suggests that individualized reconstruction techniques should be applied for pediatric patients undergoing LDLT using an LL graft with variant MHV anatomy.

Case Report

Living donor liver transplantation with hyperreduced segment II monosegment graft for an infant weighing 3 kilograms

Jung-Man Namgoong¹ , Gil-Chun Park¹ , Shin Hwang¹ , Sang-Hoon Kim¹ , Suhyeon Ha¹ , Kyung Mo Kim² , Seak Hee Oh²

Ann Liver Transplant 2023; 3(1): 50-56

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Abstract : In liver transplantation for small infants, graft-size matching to the recipient’s abdomen is the most important factor for successful transplantation. We herein present the surgical technique and clinical outcome of pediatric living donor liver transplantation (LDLT) using a hyperreduced segment II monosegment (HRS2MS) graft in an infant weighing 3 kilograms (kg). A female patient was prematurely born at 28 weeks 5 days with a body weight of 1,030 g. At 4 months after birth, LDLT was performed due to progression of liver failure with deterioration of the general condition and vital signs at the patient body weight of 3.0 kg. Considering that her height was 49 cm at transplantation, her ideal body weight was estimated to be only 2.1 kg. The living donor was a 33-year-old mother of the patient. A HRS2MS graft of 123 g was recovered, which was equivalent to a graft-to-recipient weight ratio of 4.1%. The standard surgical procedures for pediatric LDLT were performed. Because the recipient’s native liver was enlarged and weighed 336 g and there was massive ascites, primary closure of the abdomen was successfully performed. Follow-up computed tomography studies showed uneventful graft implantation. Currently, she has been doing well for more than three months after transplantation. In conclusion, pediatric LDLT using a HRS2MS graft can be a useful option for treating a very small infant although large-for-size graft-related issues still remain to be solved.

Case Report

Preemptive resection of choledochal cyst during redo resection of gallbladder cancer following laparoscopic cholecystectomy

Dae Hyeon Won , Shin Hwang , Yumi Kim

Ann Liver Transplant 2023; 3(1): 57-62

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Abstract : Choledochal cyst is associated with biliary malignancies such as bile duct cancer and gallbladder cancer. We herein present a case of preemptive choledochal cyst resection during redo operation for incidentally detected gallbladder cancer following laparoscopic cholecystectomy. A 64-year-old female patient underwent laparoscopic cholecystectomy and gallbladder cancer was diagnosed. Imaging studies revealed that the patient had choledochal cyst with anomalous union of the pancreaticobiliary duct. Preoperative findings suggested that gallbladder cancer might have be developed due to the carcinogenic effect of the anomalous union of the pancreaticobiliary duct-associated pancreatic reflux. Thus, preemptive resection of choledochal cyst was performed with redo radical cholecystectomy. The patient recovered uneventfully. The tumor stage was T2N0M0, tumor-node-metastasis stage II. The patient has been undergoing adjuvant chemotherapy. The present case suggests that preemptive bile duct resection can be considered in gallbladder cancer patients with anomalous union of the pancreaticobiliary duct and asymptomatic choledochal cyst.