Oral (pre-recorded)
OT02 Transplantation: Living Donor 
Selection of Presentations from Abstract Submissions
OT02-01 Impact of Middlehepatic Artery Reconstruction after Livingdonor Liver Transplantation Using the Left Lobe
Noboru Harada, Japan

N. Harada, T. Yoshizumi, H. Uchiyama, T. Ikegami, S. Itoh, T. Toshima, M. Mori
Kyushu University, Japan

Introduction: The aim of this study was to clarify the impact of middle hepatic artery reconstructionon the outcomesof duct-to-duct biliary anastomosis after living-donor liver transplantation (LDLT) using left lobe.
Materials and methods: Amongtwo hundred and fifty eight LDLTs using the left lobe, 216 LDLT patients which underwent hepatic artery reconstruction and one hepatic duct reconstruction with duct-to-duct interrupted anastomosis were divided into three groups: Group A (n= 123), one stump with left hepatic artery reconstruction; Group B (n = 32), 2 stumps with only left hepatic artery reconstruction; Group C (n = 61), 2 stumps with left and middle hepatic arteries reconstruction. We compared the outcomes among three groups after LDLT using left lobe.
Results: Hepatic artery complications did not occur in our study. There were no differences of graft survivals between the three groups. The Group B patients had a significantly greater incidence of anastomotic biliary stricture than that of Group C. A multivariate analysis with Cox regression revealed that Group B (the presence of a nonreconstructed MHA) was the only significant independent risk factor for postoperative anastomotic biliary stricture after LDLT.The percentage of early anastomotic BS in the Group B (15.6%) was significantly higher than that in the Group C (5.0%).
Conclusions: We performed middle and left hepatic artery reconstruction safely ever and may have the merit of preventing biliary stricture by dual hepatic artery reconstruction when the recipient hasleft and middle hepatic artery stumps.
OT02-02 Circulating Cancer Stem Cells in Hepatocellular Carcinoma: A Pilot Study of Prediction for Tumor Recurrence after Living Donor Liver Transplantation
Hyeo Seong Hwang, Korea, Republic of

H.S. Hwang1, J.E. Yoo2, D.H. Han1, J.S. Choi1, J.G. Lee3, D.J. Joo3, M.S. Kim3, G.H. Choi1, Y.N. Park2
1Division of HBP Surgery, Department of General Surgery, Yonsei University College of Medicine, Korea, Republic of, 2Department of Pathology and Integrated Genomic Research Center for Metabolic Regulation, Yonsei University College of Medicine, Korea, Republic of, 3Division of Transplantation, Department of General Surgery, Yonsei University College of Medicine, Korea, Republic of

Introduction: The optimal indication of LT in HCC patients has evolved from Milan criteria to morphologic criteria with biologic markers. The role of circulating cancer stem cells has not been reported in patients who underwent LT for HCC.
Method: From April 2014 to March 2017, 25 patients who underwent LDLT for HCC were prospectively enrolled. EpCAM, CD90 and EpCAM/CD90 were sorted by FACS and mRNA expression of EPCAM, KRT19, THY1 were analyzed by RT-PCR in peripheral blood at preoperative, postoperative day 1 and 7, respectively. The median follow-up duration was 40 months.
Results: The mean age was 55.9 years, and HBV was the most common underlying liver disease (88%). 10 patients were above Milan criteria at diagnosis. HCC recurred in 4 patients. The detected numbers of EpCAM (+) cells and CD90 (+) cells were well correlated with mRNA expression levels in the peripheral blood (P< 0.05). EpCAM protein in HCC tissue was highly expressed in patients with recurrence (66% vs. 20%). (p=0.172). HCCs with EpCAM (+) protein expression showed more detection of EpCAM (+) circulating cells than EpCAM (-). The detection of EpCAM (+) or EpCAM(+)/CD90(+) cells before surgery and at postoperative day 1 were significantly associated with HCC recurrence after LT (p< 0.05 for all).
Conclusion: Detection of EpCAM (+) or EpCAM(+)/CD90(+) cells in the peripheral blood before surgery and at postoperative day 1 was the only variable significantly associated with HCC recurrence after LDLT but should be validated in a large-scale prospective study.
OT02-04 Outcomes of Robotic Living Donor Right Hepatectomy from 52 Consecutive Cases: Comparison with Open and Laparoscopy-assisted Donor Hepatectomy
Seoung Yoon Rho, Korea, Republic of

S.Y. Rho, J.G. Lee, D.J. Joo, M.S. Kim, S.I. Kim, D.H. Han, J.S. Choi, G.H. Choi
Department of Surgery, Yonsei University College of Medicine, Korea, Republic of

Objective: To investigate the feasibility and safety of an alternative robotic living-donor right hepatectomy (RLDRH) technique.
Background data: Data for minimally invasive living-donor right hepatectomy, especially RLDRH, in a relatively large donor cohort have not been reported yet.
Methods: From March 2016 to March 2019, 52 liver donors underwent RLDRH. The clinical and perioperative outcomes of RLDRH were compared with those of conventional open donor right hepatectomy (CODRH; n=62) and laparoscopy-assisted donor right hepatectomy (LADRH; n=118). Donor satisfaction with cosmetic results was compared between RLDRH and LADRH using a body image questionnaire.
Results: Although RLDRH had a longer operative time (RLDRH, 493.6 min; CODRH, 404.4 min; LADRH, 355.9 min, p< 0.001), its mean estimated blood loss was significantly lower (RLDRH, 109.8 mL; CODRH, 287.1 mL; LADRH, 265.5 mL; p< 0.001). The postoperative complication rates were similar among the three groups (RLDRH, 23.1%; CODRH, 35.5%; LADRH, 28.0%; p=0.420). Regarding donor
satisfaction, the body image and cosmetic appearance scores were significantly higher in RLDRH than in LADRH. There was no significant difference in hospital stay among the three groups (p=0.105). After propensity score matching, RLDRH showed a shorter hospital stay and similar complication rate than CODRH.
Conclusions: RLDRH resulted in a similar postoperative complication rate and shorter length of hospital stay compared with those of CODRH and provided better body image and cosmetic results compared with those of LADRH. RLDRH is feasible and can be safely performed by expert surgeons in both robotic systems and open hepatectomy.
Variables (Mean ± SD)RLDRH 1 (N=52)CODRH 2 (N=62)LADRH 3 (N=118)pP (1-2)P(2-3)P(1-3)
Age (yrs)28.6 ± 8.728.7 ± 8.336.9 ± 12.1<0.0010.937<0.001<0.001
Body mass index (kg/m2)22.4 ± 2.122.1 ± 2.423.3 ± 2.50.0130.3880.0460.046
Total liver volume (ml)1178.2 ± 172.41175.0 ± 181.11253.4 ± 216.20.0090.9240.0160.028
Graft volume (ml)718.9 ± 104.3731.3 ± 124.2785.1 ± 144.20.0010.5690.0140.001
Remnant liver volume (%)38.7 ± 4.037.2 ± 3.836.9 ± 8.30.1270.0460.7620.064
GRWR (%)1.1 ± 0.21.1 ± 0.21.2 ± 0.30.0020.2270.0380.002
Total operative time(min)493.6 ± 91.5404.4 ± 47.4355.9 ± 95.7<0.001<0.001<0.001<0.001
Estimated blood loss(ml)109.8 ± 101.5287.1 ± 168.4265.5 ± 288.40.001<0.0010.527<0.001
Comprehensive complication index22.7±25.615.2±7.517.0±7.50.3270.3380.3820.460
[Comparison of clinical characteristics and operative outcome]
OT02-05 Demarcating the Exact Midplane of the Liver Using Indocyanine Green Near-Infrared Fluorescence Imaging during Laparoscopic Donor Hepatectomy
Jeesun Kim, Korea, Republic of

J. Kim, S.K. Hong, J. Lim, J.-M. Lee, J.-H. Cho, N.-J. Yi, K.-W. Lee, K.-S. Suh
Department of Surgery, Seoul National University Hospital, Korea, Republic of

Introduction: Indocyanine green (ICG) near-infrared fluoroscopy has been widely implemented in laparoscopic donor hepatectomy for precise demarcation of the liver midplane. This study aims to show the effectiveness of ICG fluoroscopy and to determine that a single injection of ICG is adequate for both midplane dissection and bile duct division.
Method: Retrospective analysis was done with recordings of 46 laparoscopic living donor hepatectomies performed between June 2016 and May 2017. Intraoperatively, vascular inflow of the targeted hemiliver was temporarily clamped so that the ischemic line dividing the two lobes would become visible, and ICG was injected intravenously (0.025mg/kg). Images were captured in the natural, black-and-white, and fluorescent views, and the color values of the clamped vs non-clamped regions were quantitated. Additionally, the time from ICG injection to bile duct illumination and then to fluoroscopy termination were measured.
Results: The color differences between the clamped vs non-clamped regions in the natural, black-and-white, and fluorescent views were 39.7±36.2, 89.6±46.9, and 19.1±36.8 (P< 0.001), respectively, demonstrating that ICG visualized in the black-and-white view is most effective for midplane demarcation. Furthermore, the time from ICG injection to bile duct illumination and that from bile duct illumination to fluoroscopy termination were 85.6±25.8mins and 8.7±4.8mins, respectively, indicating that a single injection of ICG is adequate for midplane dissection followed by bile duct division.
Conclusion: ICG injection visualized in black-and-white is most effective for demarcating the liver midplane during laparoscopic donor hepatectomy. Also, a single injection of ICG is sufficient for midplane dissection and bile duct division.
OT02-06 Biliary Reconstruction Using High Biliary Radical Is Safe Option for Multiple Graft Bile Ducts in Right Lobe Living Donor Liver Transplantation
Joodong Kim, Korea, Republic of

J. Kim, D. Choi, E. Jwa
Department of Surgery, Catholic University of Daegu College of Medicine, Korea, Republic of

Multiple small size donor bile ducts (BDs) are related to higher incidence of biliary complications (BCs) and biliary reconstruction for multiple BDs still remains a technical challenge during living donor liver transplantation (LDLT). Especially biliary reconstructions using high biliary radicals (right or left hepatic duct) on the recipient for multiple BDs are associated with very high probability of BCs secondary to devacularization and ischemia. Therefore, hepaticojejunostomy has been preferred in cases with multiple BDs which are not close each other although duct to duct anastomosis (DDA) has more physiological advantages. Herein, we analyzed clinical outcomes through retrospective reviews 227 patients receiving DDA for right lobe grafts LDLT from January 2013 to September 2018. 87 LDLT using grafts with multiple BDs have been performed and among them, 39 patients received DDA using high biliary radicals as recipient's BD using minimal hilar dissection, external biliary stents and mucosal eversion technique. We compared clinical outcomes with those in group using common hepatic duct as recipient's BD for multiple BD (CHD group). The incidence of biliary leakage and stricture were 10.3% and 12.8% and these results were not different to those in CHD group. Moreover, these results were comparable to those in group with single graft BD during the same periods. In conclusion, the choice high biliary radicals as the recipient's BD for multiple graft BDs was not associated with more BCs and could be safe option for biliary reconstruction with multiple BDs under our strategies.
OT02-07 Totally Laparoscopic and Conventional Open Living Donor Right Hepatectomy: A Comparative Study of Outcomes
Young Seok Han, Korea, Republic of

Y.S. Han, J.R. Han, J.M. Chun, Y.J. Hwang
Hepato-Biliary-Pancreas Surgery and Liver Transplantation, Kyungpook National University School of Medicine/Kyungpook National University Hospital, Korea, Republic of

Although laparoscopic liver resection has progressively developed with increased surgical experience and the improvement of laparoscopes and specialized instruments, only a limited number of centers have performed laparoscopic living donor hepatectomy(LDRH) . We describe the experiences and outcomes associated with LDRH in adult-to-adult LDLT in order to assess the safety of the totally laparoscopic technique in donors.
Between December 2014 and October 2018, we performed 97 cases of living donor right hepatectomy. Among them, 50 donors underwent totally laparoscopic living donor right hepatectomy and 47 donors underwent conventional open living donor right hepatectomy. We retrospectively reviewed the medical records to ascertain donor safety and the reproducibility of LDRH.
The total operation time was longer (367.0±74.3 vs 323.5±62.5; P=.002) and the warm ischemic time was also longer(9.2±4.6 vs 1.8±1.6;P< .002) in LDRH group. However, the length of postoperative hospital stay was similar in both groups and no donors in LDRH group required blood transfusion, conversion to open surgery, or reoperation. There was no postoperative mortality. Postoperative complication of Clavien-Dindo classification III or more was identified in only one donor who had a minor bile leakage from the cutting edge of the right hepatic duct stump requiring endoscopic biliary stent insertion. All the liver function tests returned to normal ranges within 2 weeks.
In conclusion, our study reveals LDRH seems to be a safe and feasible procedure with acceptable outcomes. However, LDRH can be initially attempted after attaining sufficient experience in laparoscopic hepatectomy and LDLT techniques.
OT02-08 Donor Biliary Anatomy: Not a Determinant of Biliary Complications after Right Lobe Living Donor Liver Transplantation
Ashish Singhal, India

A. Singhal, K. Makki, V. Chorasiya, A. Srivastava, A. Khan, M. Qaleem, V. Vij
Liver Transplantation & HPB Surgery, Fortis Hospitals, India

Background: Donor biliary anatomy may contribute to postoperative biliary complications in donors and recipients following right lobe living-donor liver transplantation (RL-LDLT).
Methods: Retrospective analysis of medical records of 1105 consecutive (12/ 2011 - 06/2019) donors and recipients who underwent RL-LDLT at our center. The donors and recipients were divided into 2 groups (with and without postoperative biliary complications) and were compared. The primary endpoints were donor biliary anatomy type and postoperative biliary complication incidence; the secondary endpoints were 1-, 3- and 5-year graft and patient survival rates.
Results: Based on intraoperative cholangiogram among donors, 855 (77.3%) had type A, 141 (12.8%) had type B, 71 (6.4%) had type C, 25 (2.2%) had type D, and 13 (1.2%) had type E biliary anatomy.
Biliary complications occurred in 37 donors (3.3%): bile leakage in 33, intraoperative bile duct injury in 2, and biliary stricture in 2. The most common reason for biliary complications among donors was missed caudate duct(s). Seventy-four (6.7%) recipients developed biliary complications: 20 had bile leak, 43 had biliary stricture, and 11 developed blie leak + stricture. Sarcopenia was the only significant factor for biliary complications in recipients.
None of the donor had long-term sequelae. Recipients with biliary complications had inferior graft and patient survival.
Conclusions: The incidence of biliary complications in donors or recipients after RLDLT was not related to donor biliary anatomy type. With standardized surgical technique, biliary complications can be minimized and donor biliary anatomy should not be considered a contraindication to right lobe liver donation.
OT02-09 Living Donor vs Deceased Donor Liver Transplantation in Adults: Clinical Results and Survival Analysis in a Latin American Transplant Center
Gabriela Ochoa, Chile

G. Ochoa1, E. Briceño1, J.P. Arab2, C. Benitez2, R. Wolff2, F. Barrera2, N. Jarufe1, J. Martinez1, M. Dib1
1Digestive Surgery, Pontificia Universidad Católica de Chile, Chile, 2Hepatology, Pontificia Universidad Catolica de Chile, Chile

Introduction: Latin America faces a critical situation due to very low donation rates. In Chile, the annual dropout rate from the list for liver transplantation (LT) is 37.6%. In 2016, our center started an adult-to-adult living donor liver transplantation (LDLT) program. We compared the first 20 LDLT cases with deceased donor liver transplants (DDLT) during the same period.
Method: Prospective single center cohort of 129 LT from April 2016-November2019, excluding 26 patients who didn't meet criteria for LDLT candidacy (acute liver failure, combined or re-transplant). We compared 20 LDLT vs 83 DDLT pre-transplant clinical conditions, outcomes and survival rate using non-parametric and Fisher's exact tests, and Kaplan Meier curves.
Results: LDLT patients had lower MELD (20 vs 26 p< 0.05). LDLTs had shorter time on the wait-list compared to all DDLT (12.1 vs 20.9 weeks, p=NS), which became significant when compared to the group of DDLT with MELD < 30 (12.1 vs 40.0 weeks, p< 0.05). Both had similar overall complications (65% vs 60% p=NS), Clavien-Dindo >IIIA (45% vs 49,4% p=NS) and reoperations(40% vs 37.3%p=NS). LDLT had lower rejection and re-transplant rates, but had more biliary complications (50% vs 15.7%p< 0.05), mostly bile leaks (45% vs 6% p< 0.05). Overall and graft survival were similar (log-rank p=0.995).
Conclusions: LDLT is a good alternative in a Latin American country with low donation rates. Compared to DDLT, LDLT increases access to LT by decreasing time on the wait-list, reaching transplant with lower MELD scores, maintaining similar overall complications and survival rates.
[LDLT vs DDLT: Survival Analysis]
OT02-10 Pure Laparoscopic versus Open Right Hepatectomy in Live Liver Donors: A Propensity Score Matched Analysis
Suk Kyun Hong, Korea, Republic of

S.K. Hong, M.Y. Tan, L. Worakitti, J.-M. Lee, J.-H. Cho, N.-J. Yi, K.-W. Lee, K.-S. Suh
Seoul National University Hospital, Korea, Republic of

Background: Although PLDRH is gradually spreading worldwide, their outcomes including long-term outcomes of both donor and recipient have not yet been evaluated in a large comparative study. The aim of this study is to present the safety and feasibility of pure laparoscopic donor right hepatectomy (PLDRH) compared with that of conventional donor right hepatectomy (CDRH).
Methods: We retrospectively reviewed the medical records of 894 donors who underwent LDLT between January 2010 to September 2018 at Seoul National University Hospital were reviewed. We performed 1:1 propensity score matching between the PLDRH and CDRH groups. Subsequently, 198 donor and counter recipients were included in each group.
Results: The total operation time (P< 0.001), time to remove the liver (P< 0.001), and warm ischemic time (P< 0.001) were longer in the PLDRH group. The length of postoperative hospital stay was significantly shorter in the PLDRH group (P< 0.001). Although the rate of complication in donor was similar between the two groups, the rates of early (P=0.019) and late (P< 0.001) biliary complication in recipient were higher in PLDRH group. There was no significant difference in overall survival and graft survival between the two groups.
Conclusion: PLDRH is feasible when performed at an experienced LDLT center. Further studies on long-term recipient outcomes including biliary complications are needed to confirm the safety.
OT02-11 Randomized Trial between Histidine-tryptophan-Ketoglutarate [HTK] and Institute of Georges Lopez [IGL-1] Perfusion Solutions in Living Donor Liver Transplantation [LDLT]
Mathews Michael, India

M. Michael, L.S. Raju, J.S. Mathew, B. S T, U. Gopalakrishnan, D. Balakrishnan, R. Menon, S. Othiyil Vayoth, S. Surendran
Department of GI Surgery and Solid Organ Transplant, Amrita Insititute of Medical Sciences Kochi, India

Aim: In DDLT, there has been recent evidence for superiority of IGL-1 solution over HTK in terms of graft survival. Here we aim to compare Early Allograft Dysfunction [EAD] and recipient outcomes in Living-donor-liver-transplantation[LDLT] grafts perfused with either HTK or IGL-1 solution on the bench.
Materials and methods: From Feb2018 to Nov2019, 156(138M:18F)adult patients undergoing LDLT[after excluding ABOincompatible(n=1), pediatric(n=19), APOLT(n=1) and DDLT(n=5)], were randomized to two groups by computerized block randomization. Early graft dysfunction[defined by Olthoff criteria], peak postop transaminases, incidence of biliary complications, hepatic artery thrombosis[HAT] and 6 month graft survival were compared between two groups.
Results: Both groups were matched in terms of baseline characters and intraoperative parameters. The early deaths(within 5days of transplant) are comparable in both groups (IGL1:n=3; HTK:n=3).There is no statistically significant difference in incidence of EAD[IGL-1 - 9(11.54%) vs HTK - 13(18.06%), p=0.26]. However peak transaminase levels in first week and day1 transaminases are significantly lower in the IGL-1 group [peak alanine transaminase(pALT): IGL-1(397.08±350.75) vs HTK(604.23±652.54); p=0.015, peak aspartate transaminase(pAST): IGL-1(383.55±329.46) vs HTK(555.85±460.50); p=0.0089 and day1 ALT: IGL-1(317.37±245.51) vs HTK(442.95±498.79); p=0.049; day1 AST: IGL-1(348.65±301.30) vs HTK(458.62±351.62);p=0.041]. Day 3 and 5 transaminase levels are also lower in IGL-1 group but without statistical significance. There is no significant difference in incidence of ACR, HAT and biliary complications between two groups.
Conclusions: Recipients of grafts perfused with IGL-1 have significantly lower peak and day 1 transaminase levels compared to HTK. However there is no difference in EAD, biliary complications, rejections or HAT between two groups.
OT02-13 Outcome of Portal Vein Reconstruction Using Branch Patch Anastomosis in Pediatric Living Related Liver Transplant Recipients Weighing Less than 10 kg
Roshan Ghimire, India

R. Ghimire, S. Gupta
Max Super Speciality Hospital, India

Pediatric living related liver transplantation (PLRLT) in children less than 10 Kg of weight with Portal vein (PV) reconstruction in atretic and hypoplastic portal vein is challenging. Portal venoplasty using branch patch anastomosis is one of the techniques that are being advocated for these groups of patients.
This is a consecutive cohort study of 67 PLRLT patients with weight less than 10kg in the department from January 2015-September 2019. 21 patients underwent portal vein reconstruction with an interposition vein graft (IPVG) and 46 patients underwent branch patch anastomosis (BPA). Clinical characterisatics, incidence of portal vein complications and mortality of both groups were compared using chi-square test with p- value < 0.05 is considered significant.
6 out of 46( 13 %) patients in branch patch anastomosis group and 3 out of 21(14.3 %) in interposition vein graft group developed portal vein thrombosis (p = 0.8). All patients (8/67=11.9%) who developed Portal vein thrombosis were managed surgically. Among the patients who developed PVT, 2/6 in BPA group and 2/3 in IPVG group died (p= 0.8).
Branch patch anastomosis (BPA) for portal vein size enlargement is acceptable surgical technique compared to interposition vein graft for portal vein reconstruction. Portal vein complications and mortality for both the groups are comparable in pediatric living related liver transplantation (PLRLT) in children less than 10 Kg of weight.