Replacing the retrohepatic inferior vena cava (IVC) following concurrent resection of the IVC and tumor-involved liver is an emerging surgical technique in living donor liver transplantation (LDLT), particularly for managing hepatocellular carcinomas near the IVC. This approach makes the extent of hepatectomy in LDLT comparable to that of deceased donor liver transplantation. We report a pediatric LDLT case involving IVC and portal vein (PV) replacement with an iliac vein homograft to treat advanced hepatoblastomas. The patient was a 24-month-old girl weighing 9.1 kg, presenting with large, multiple hepatoblastomas infiltrating the retrohepatic IVC and PV. After a 2-week waiting period, a cold-stored iliac vein graft was obtained, and the transplantation was performed using a left lateral section graft from her father.A 4-cm iliac vein homograft was anastomosed between the suprahepatic and suprarenal IVC stumps. The liver graft was implanted following standard procedures, with the PV reconstructed via a telescope-shaped anastomosis using the vein graft interposition. The patient experienced an uncomplicated recovery and is currently receiving scheduled adjuvant chemotherapy. In conclusion, IVC and PV replacement with vein homografts represents a feasible and effective surgical strategy for pediatric LDLT patients with advanced liver malignancies involving vascular invasion.

Background: A systematic evaluation of potential living liver donors is essential to ensure donor safety and optimize recipient outcomes in living donor liver transplantation (LDLT). This study aimed to assess donor acceptance rates and reasons for disqualification among individuals evaluated for LDLT at a high-volume transplant center over a one-year period. Methods: We retrospectively reviewed 1,087 potential living liver donors who presented for LDLT evaluation in 2023. Of these, 991 candidates advanced beyond the initial screening (Stage 1) and underwent comprehensive clinical, imaging, and pathological assessments (Stages 2 and 3). Candidates who discontinued after Stage 1 were excluded due to the absence of documented reasons for non-progression. Results: Among the 991 candidates who proceeded beyond initial screening, 473 (47.7%) completed the full donor evaluation, of whom 466 were judged to be suitable donors. Among suitable donors, 384 (82.4%) proceeded to donor hepatectomy, whereas 82 did not, primarily due to recipient-related factors such as clinical deterioration or withdrawal of consent. Donor ineligibility was determined in 422 candidates (42.6%), most commonly due to inadequate remnant liver volume (52.8%), hepatic steatosis (20.6%), and insufficient graft size (10.2%). Among candidates undergoing Stage 2 evaluation, 162 (16.3%) failed to meet steatosis criteria; 126 were excluded solely for steatosis and advised weight reduction, and 39 subsequently became eligible and successfully donated. Conclusion In this high-volume LDLT center, donor disqualification was primarily driven by remnant liver volume and hepatic steatosis. Targeted interventions such as weight reduction enabled successful donation in a subset of initially ineligible candidates, underscoring the importance of individualized donor evaluation and pre-donation optimization.

Background: We developed a simplified variant of the ADV score, the AFP-PIVKAII (AP) score for post-transplant hepatocellular carcinoma (HCC) prognosis, which considers only AFP and PIVKA-II levels excluding morphometric tumor size information from the ADV score. This study investigated the prognostic performance of the AP score in predicting HCC recurrence and overall survival (OS) after living donor liver transplantation (LDLT). Methods: We analyzed 843 patients with HCC who underwent LDLT between 2006 and 2015, assessing HCC recurrence and OS in relation to AP score. Results: The median pretransplant AFP and PIVKA-II levels were 12.8 ng/mL and 27 mAU/mL, respectively. The median and mean AP scores were 2.6 log (range: 0.6–9.2 log) and 2.9±1.1 log, respectively. The 5-year time-dependent area under the receiver operating characteristic curve for the AP score in predicting post-transplant HCC recurrence was 0.672 (p<0.001). HCC recurrence and OS curves along AP score intervals of 1.0 log showed statistical differences in accordance with the AP scores (both p<0.001). Using a Youden index J-derived AP score cutoff of 4.0 log, two-tiered groups (ADV <4.0 log vs. ADV ≥4.0 log) showed statistically significant differences in HCC recurrence and OS (both p<0.001). Harrell’s c-indices for AP score with cutoff of 4.0 log and ADV scores with cutoff of 5.0 log regarding HCC recurrence and OS were similar. Conclusion The AP score functions as an integrated surrogate marker for predicting post-transplant outcomes in patients with HCC undergoing LDLT. It may serve as a simplified alternative to the ADV score, particularly in patients with small HCCs.

Background: Studies on whether donor-to-recipient sex match status affects long-term survival after liver transplantation (LT) have yielded contradictory results. This study evaluated whether donor-to-recipient sex match status influenced long-term survival after living donor liver transplantation (LDLT) or deceased donor liver transplantation (DDLT) at a high-volume center. Methods: The study included 6,664 patients who underwent primary LT between January 2000 and December 2022 at our institution. Patients were divided into four groups according to donor-to-recipient sex match status: male-to-male (n=3,427 [51.4%]), male-to-female (n=1,152 [17.3%]), female-to-male (n=1,385 [20.8%]), and female-to-female (n=700 [10.5%]). Results: Regarding clinical characteristics, the four groups differed significantly regarding background liver disease (P<0.001), model for end-stage liver disease score (P<0.001), serum protein induced by vitamin K absence or antagonist II level (P=0.003), presence of concurrent hepatocellular carcinoma (HCC; P<0.001), and type of LT (P=0.003). Overall survival (OS) of all LT recipients did not differ significantly among the groups (P=0.377). Donor-to-recipient sex match status did not affect long-term OS in either LDLT (P=0.176) or DDLT (P=0.220) groups. In addition, sex match status did not significantly influence posttransplant OS among patients who underwent LDLT without HCC (P=0.464), LDLT with HCC (P=0.236), DDLT without HCC (P=0.338), or DDLT with HCC (P=0.818). Conclusions Donor-to-recipient sex match status does not significantly affect posttransplant patient survival or HCC prognosis after LDLT or DDLT.

In children with biliary atresia, recurrent episodes of cholangitis often lead to portal vein (PV) phlebosclerosis. We report a case of pediatric living donor liver transplantation (LDLT) for biliary atresia with PV occlusion and a large splenorenal shunt. A 3-year-5-month-old girl was diagnosed with syndromic biliary atresia and polysplenia. Because the patient’s condition progressively deteriorated with worsening jaundice, we opted to perform LDLT using a left lateral section graft from her father. The recipient’s native PV was severely atrophic and completely occluded, and the collateral veins around the hepatoduodenal ligament were too small to serve as a viable source of portal inflow.Consequently, renoportal anastomosis (RPA) was selected as an alternative approach.Iliac vein interposition was performed to provide a new portal inflow source, and anatomy-compliant PV reconstruction was performed. The patient recovered from transplant surgery, but PV conduit stenosis occurred with the development of ascites 2 months posttransplant. This RPA-related vascular complication was resolved through percutaneous balloon angioplasty of the PV conduit. The patient has been doing well for 6 months posttransplantation. This case demonstrates that RPA can represent a viable reconstructive option for PV inflow in liver transplantation for pediatric patients with phlebosclerotic PV and prominent splenorenal shunt.

Replacement of the retrohepatic inferior vena cava (IVC) after concurrent resection of IVC and tumor-bearing liver is regarded as a feasible living donor liver transplantation (LDLT) technique to cope with tumors around the IVC. This method can make the resection extent of LDLT comparable to that of deceased-donor liver transplantation. We present one pediatric LDLT case with IVC replacement using an enlarged iliac vein conduit to treat advanced hepatoblastoma. The patient was a 33-monthold and 12 kg-weighing girl suffering from large multiple hepatoblastomas invading the retrohepatic IVC. At 2-month waiting after deciding LDLT, we obtained a coldstored iliac vein graft and LDLT was performed with the father’s left lateral section graft. A 1.3 cm-wide and 10 cm-long iliac vein was transformed to be a 2 cm-wide and 5 cm-long vein graft through a double-barrel unification venoplasty. The left lateral section graft was implanted along the standard procedure of LDLT. The patient recovered uneventfully and is undergoing scheduled adjuvant chemotherapy. IVC replacement with vein homograft is a feasible option for LDLT in pediatric patients with advanced liver malignancy.

Purpose: Huge (≥10 cm) hepatocellular carcinoma (HCC) poses significant treatment and prognosis challenges. This study aimed to determine whether preoperative transarterial chemoembolization (TACE) for huge HCC is necessary. Methods: This single-center, retrospective cohort study evaluated 435 patients with huge HCC who underwent upfront hepatectomy or hepatectomy after preoperative TACE from January 2009 to December 2018. TACE’s impact on survival and prognostic factors, including microvascular invasion (MVI) and satellite nodules (SNs), was analyzed. Results: The preoperative TACE group (n = 33) had a lower incidence of MVI (P = 0.009) and higher postoperative morbidity (P = 0.001), particularly pleural effusion (P = 0.004) and Clavien-Dindo class III–IV complications (P = 0.033), compared with the upfront hepatectomy group (n = 402). Short-term mortality (P = 0.828) and recurrence within 6 months (P = 0.654) were comparable between groups. The 1-, 3-, and 5-year survival curves showed no significant between-group differences in recurrence-free survival (RFS) (P = 0.172) and overall survival (OS) (P = 0.450). Local regional therapy for intrahepatic recurrences and surgical resection for extrahepatic recurrences were associated with better OS. MVI, SN, and hepatic vein tumor thrombosis were identified as significant risk factors for poorer RFS and OS. In patients without SN, preoperative TACE improved RFS (P = 0.039) but not OS. Conclusion Preoperative TACE for huge HCC was associated with reduced MVI but did not improve RFS and OS. Survival outcomes were more significantly influenced by SN, suggesting that upfront hepatectomy without TACE should be prioritized.

Purpose: This study aimed to describe adult living donor liver transplantation (LDLT) for acute liver failure and evaluate its clinical significance by comparing its surgical and survival outcomes with those of deceased donor liver transplantation (DDLT). Methods: We retrospectively reviewed the medical records of 267 consecutive patients (161 LDLT recipients and 106 DDLT recipients) aged 18 years or older who underwent liver transplantation between January 2006 and December 2020. Results: The mean periods from hepatic encephalopathy to liver transplantation were 5.85 days and 8.35 days for LDLT and DDLT, respectively (P = 0.091). Among these patients, 121 (45.3%) had grade III or IV hepatic encephalopathy (living, 34.8% vs. deceased, 61.3%; P < 0.001), and 38 (14.2%) had brain edema (living, 16.1% vs. deceased, 11.3%; P = 0.269) before liver transplantation. There were no significant differences in in-hospital mortality (living, 11.8% vs. deceased, 15.1%; P = 0.435), 10-year overall survival (living, 90.8% vs. deceased, 84.0%; P = 0.096), and graft survival (living, 83.5% vs. deceased, 71.3%;P = 0.051). However, postoperatively, the mean intensive care unit stay was shorter in the LDLT group (5.0 days vs. 9.5 days, P < 0.001). In-hospital mortality was associated with vasopressor use (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.45–7.96; P = 0.005) and brain edema (OR, 2.75; 95% CI, 1.16–6.52; P = 0.022) of recipient at the time of transplantation. However, LDLT (OR, 1.26; 95% CI, 0.59–2.66; P = 0.553) was not independently associated with in-hospital mortality. Conclusion LDLT is feasible for acute liver failure when organs from deceased donors are not available.

Liver transplantation is accepted as an effective therapeutic option for unresectable hepatoblastoma. We present a pediatric case of hepatoblastoma patient with portal vein (PV) tumor thrombosis (PVTT) that occluded the main PV completely despite aggressive neoadjuvant chemotherapy. The patient was a 4-year and 2-month-old 17-kg boy suffering from hepatoblastoma with PVTT, which was partially regressed by neoadjuvant chemotherapy. Viable PVTT remained after right trisectionectomy and repetition of systemic chemotherapy. To remove the tumor completely, we performed living donor liver transplantation (LDLT) using his father’s left liver graft.The native PV was completely occluded with PVTT and abundant pericholedochal collaterals developed. The native PV was meticulously dissected to fully expose the superior mesenteric vein-splenic vein confluence. This confluence portion was deeply clamped and opened to use as a viable PV inflow source. A cold-stored fresh external iliac vein homograft was anastomosed to the confluence portion as an end-to-end fashion and passed through the native retropancreatic PV tract after mechanical dilatation of the tract. Left liver graft implantation was performed using standard procedures of pediatric LDLT. The patient recovered uneventfully. He will undergo scheduled adjuvant chemotherapy. Customized design for PV reconstruction using interposition vein graft with viable PV inflow source can result in successful PV reconstruction with complete removal of PVTT.

Background: As the prevalence of obesity and nonalcoholic fatty liver disease increases in recent years, the number of living donor liver transplantation from donor with high body mass index (BMI) is increasing. However, data on the effect of high BMI on outcomes in liver donors are lacking. This study aimed to investigate the influence of donor obesity (BMI ≥30 kg/m2 ) on and clinical outcomes after donor right liver resection (DRLR). Methods: Records of all living donors who underwent DRLR between January 2015 and December 2020 at Asan Medical Center were retrospectively reviewed. We divided donors into obese (BMI ≥30 kg/m2 , n=41) and normal-weight (BMI ≤25 kg/m2 , n=1,125) groups. To eliminate bias, matching was performed using the greedy method, and 34 donors involved in this study in each group. Results: After matching, preoperatively, the obese group had significantly higher preoperative levels of serum aspartate aminotransferase (p=0.021), alanine aminotransferase (p=0.003), and a larger celiac artery depth ratio (p<0.001) and graft volume (p<0.001) than the normal-weight group. When comparing perioperative outcomes of donor, the operation time was longer in the obese group (p=0.019), but no difference was observed in postoperative major complication rates (p=0.314), lengths of hospital stay (p=0.607), and readmission rate (p>0.999). Furthermore, both groups had similar major surgical outcomes of recipients including biliary (p=0.163) complications and lengths of hospital stay (p=0.445). Conclusion DRLR may be safely performed in a select group of high BMI donors with ≥30 kg/m2 without uncontrolled metabolic disease and significant liver steatosis in the absence of other suitable living donors.