Poster
Transplant 		  
PT01 Transplantation: Liver (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PT01-02 Using Direct-Acting Antiviral Therapy before Transplanting Hepatitis C Virus-Positive Livers into Hepatitis C Virus-Negative Patient: A Case Sharing in Chi-Mei Hospital
Sheng-Hsun Kao, Taiwan, Republic of China

S.-H. Kao, D.-P. Sun
Division of General Surgery, Department of Surgery, Chi-Mei Medical Center, Taiwan, Republic of China

Under current guidelines hepatitis C virus (HCV)-positive livers are not transplanted into HCV negative recipients because of adverse post-transplant outcomes associated with allograft HCV infection. However, HCV can now be cured post liver transplant (LT) using direct-acting antivirals (DAAs) with >90% success. Here we report a case of decompensated alcohoic liver cirrhosis(Model of End stage Liver Disease(MELD) score: 34). He received living donor liver transplantation form a HCV-positive donor treated with DAA agent regimens achieved SVR before liver transplantation in chi-mei hospital. The liver transplantation was done on 2019/3/08 without major complication except some minor complication like liver abscess, bile leakage. Patient(recipient) recovered gradually and then discharged smoothly on 2018/4/28. After nearly a year of trace, the patient is not detection of hepatitis C infection.
PT01-03 Liver Allocation for Re-Transplantation - Impact of Early versus Late Re-Transplantation on Outcome
Philipp Kron, United Kingdom

P. Kron, M. Attia, R. Jones, G. Toogood, P. Lodge
St James's University Hospital, United Kingdom

Introduction: Liver re-transplantation (LrTx) is necessary for 5-20% of recipients worldwide. Allocation schemes advantage recipients with early graft failure but the opposite is true for patients needing late re-transplantation.
The aim of this study was to assess the effect of early (≤ 30 days) versus late (>30 days) LrTx on 90-day mortality and long-term survival in our centre.
Method: A retrospective, single institutional analysis was performed, assessing all patients ≥ 18 years undergoing LrTx between 2009 and 2018.
Results: 1237 adult liver transplants were performed; 112 (9%) were LrTx: 98 first LrTx, 13 second LrTx and 1 third LrTx. The main indications for re- transplantation were: ischaemic biliopathy (25%), hepatic artery thrombosis (HAT, 23.2 %) and primary non function (PNF, 23.2 %). Early LrTx accounted for 44,6 % of cases; median 4 days (range 1-29) after initial transplant. 90-day mortality rate was higher in in the early LrTx group (38%) compared to 11.3% for the late LrTx group, p< 0.0008. Reason for the high 90-day mortality rate following early LrTx was sepsis in 53%.1 year overall survival demonstrated no additional mortality in the late LrTx group but 2 additional deaths in the early LrTx group.
Conclusions: LrTx remains the curative option for graft-failure and allocation policies have favoured early LrTx for PNF and HAT. This analysis suggests that for early LrTx a cautious selection of recipients is mandatory to prevent futility associated with high 90-day mortality. Late LrTx candidates should not be disadvantaged by liver allocation policies.
PT01-04 Hepatic Artery Thrombosis Is Associated with Anastomotic Biliary Stricture after Orthotopic Liver Transplantation
Martin Bailon-Cuadrado, Spain

M. Bailon-Cuadrado, P. Marcos-Santos, B. Perez-Saborido, E. Asensio-Diaz, P. Pinto-Fuentes, J.C. Sarmentero-Prieto, D. Pacheco-Sanchez
General and Digestive Surgery, Hospital Universitario Rio Hortega, Valladolid, Spain

Introduction: Anastomotic biliary stricture is a relevant complication after orthotopic liver transplantation. The aim of this study was to analyse factors involved in the appearance of this complication.
Methods: Inclusion criteria: patients who underwent orthotopic liver transplantation between November 2001 and December 2018. Exclusion criteria: liver retransplantation. Several variables were analysed, including indication and etiology, donor and recipient sex and age, Child-Turcotte-Pugh and MELD scores, presence of arterial anomalies, arterial reconstruction, hepatic artery thrombosis, biliary anomalies, use of Kehr tube, total, warm and cold ischaemia time. Student's T for continuous variables and Chi Square for discrete variables were used for univariate analysis. Logistic regression was used for multivariate analysis.
Results: Finally, 588 patients (78.1% males, median age of 56 years) were eligible for statistical analysis. Anastomotic biliary stricture appeared in 117 (19.9%) patients. After univariate analysis, up to six variables proved to be significant: preoperative presence of ascites (p=0.024), Child-Turcotte-Pugh score (p=0.047), MELD score (p=0.048), donor arterial anomaly (p=0.032), arterial reconstruction during bench surgery (p=0.025) and hepatic artery thrombosis (p=0.049). After multivariate analysis, only hepatic artery thrombosis (this complication appeared in 9.01% of our patients) turned out to be significant (OR=2.426, 95% CI of 1.120-5.255, p=0.025).
Conclusion: Hepatic artery thrombosis seems to be an outstanding risk factor for anastomotic biliary stricture after orthotopic liver transplantation. Other arterial aspects, such as donor anomalies or the need of arterial reconstruction during bench surgery, might also have influence on the appearance of this complication.
PT01-05 Long Graft Artery and Arterial Anomalies Are Associated with Hepatic Artery Thrombosis after Orthotopic Liver Transplantation
Martin Bailon-Cuadrado, Spain

M. Bailon-Cuadrado, P. Marcos-Santos, B. Perez-Saborido, E. Asensio-Diaz, J.C. Sarmentero-Prieto, P. Pinto-Fuentes, D. Pacheco-Sanchez
General and Digestive Surgery, Hospital Universitario Rio Hortega, Valladolid, Spain

Introduction: Hepatic artery thrombosis is one of the most feared surgical complications after orthotopic liver transplantation (OLT). The aim of this study was to analyse factors involved in global, early (less than a month) and late (more than a month) hepatic artery thrombosis (HAT) after OLT.
Methods: Inclusion criteria: patients who underwent OLT between November 2001 and December 2018. Exclusion criteria: liver retransplantation. Several preoperative and intraoperative variables were analysed. Graft artery was classified as long or short when the section was located distal or proximal to the proper/common hepatic artery bifurcation. In the same way, recipient patch for arterial anastomosis was classified as distal or proximal to the proper/common hepatic artery bifurcation. Student's T for continuous variables and Chi-Square for discrete variables were used for univariate analysis. Logistic regression was used for multivariate analysis (MVA).
Results: Finally, 588 patients were eligible for statistical analysis. Global, early and late HAT appeared in 53 (9.01%), 35 (5.95%) and 18 (3,06%) patients, respectively. For global HAT, two variables proved to be significant after MVA: hepatocellular carcinoma as indication for OLT (p=0.035) and long graft artery (p=0.007). For early HAT, two variables turned out to be significant after MVA: hepatocellular carcinoma as indication for OLT (p=0.012) and arterial anomalies (p=0.036). For late HAT, only long graft artery reached statistical significance after MVA (p=0.026).
Conclusion: Technical factors involving arterial anastomosis, as the presence of arterial anomalies and the length of the graft artery, seem to be essential risk factors for HAT after OLT.
PT01-09 Can Post-Transplant Outcomes Predicted at the Time of Liver Graft Allocation?
Eunice Lee, Australia

E. Lee1,2, M. Perini1,2, G. Oniscu3, R. Jones1, G. Starkey1, B. Wang1, E. Makalic4, M. Fink1,2
1Austin Health, Australia, 2University of Melbourne, Australia, 3Edinburgh Transplant Centre, United Kingdom, 4Melbourne School of Population and Global Health, University of Melbourne, Australia

Introduction: Liver grafts are a scarce resource. Both medical urgency and expected post-transplant outcomes should be considered when allocating livers for transplantation. For allocation decisions, it is important to identify variables known at the time of liver allocation that may affect transplant outcomes.
Method: Recipient and donor data from the Australia and New Zealand Liver Transplant Registry from January 1998 to May 2019 were used. All interactions between donor and recipient variables were included. The outcome was graft failure, including patient death. Penalised regression with elastic net analysis was performed to select variables for the final multivariable Cox model. The c-statistic was used to assess score discrimination.
Results: 3734 patients were included, with 636 graft failures. 714 recipient, donor and interaction variables were considered, with 35 variables selected using elastic net for the multivariable Cox model. Variables with the largest hazard ratios were transplant for liver tumour other than hepatocellular cancer (HR 2.47, 95% CI 1.33-4.61) , retransplant with a donation after cardiac death donor (HR 2.08, CI 1.38-3.13) and split-liver graft (HR 1.5, CI 1.11-1.95). Internal validation on the same data used for model creation resulted in a c-statistic of 0.72.
Conclusions: Prediction of post-transplant outcomes from only variables known at the time of liver allocation is challenging. Further improvements are needed in the context of the prioritisation of patients for transplantation.
PT01-10 Normothermic Machine Preservation of Marginal Livers in Australasia - Initial Brisbane Experience Using a “Back-to-Base” Approach
Janske Reiling, Australia

J. Reiling1,2, N. Butler1,2, P. Hodgkinson1,2, J. Fawcett1,2
1Queensland Liver Transplant Service, Princess Alexandra Hospital, Australia, 2Faculty of Medicine, University of Queensland, Australia

Introduction: The assessment of marginal liver suitability using empirical criteria remains imprecise. Ex-vivo normothermic machine perfusion (NMP) allows for a period of graft assessment under near-physiological conditions, which might improve the selection of such livers for transplantation. We describe the first 11 clinical applications of NMP in Australasia using a “back-to-base” approach.
Methods: Eleven marginal livers were accepted for preservation and assessment on the OrganOx metra device following a period of static cold storage (post-SCS-NMP). Average donor risk index was 1.53 (1.08-1.93), with five grafts donated after brain death (DBD) and six donated after circulatory death (DCD). All DCD grafts were outside of established local criteria. Average cold ischaemic time and NMP time was 5.2 (4.2-6.5) hours and 12.0 (9.1-17.6) hours respectively. Recipient MELD score was 17 (11-20), including one combined liver-kidney transplant and one re-transplant.
Results: All livers met pre-established viability criteria and were successfully transplanted. Five (45%) recipients developed early allograft dysfunction based solely on peak AST >2000 U/L (average 1860 (629-8910) U/L, Figure 1). Two patients (18%) required revisional surgery for biliary anastomotic complications following initial Roux-en-Y hepaticojejunostomy. No clinically significant biliary problems were observed in the nine patients receiving duct-to-duct anastomosis. All cases have satisfactory graft function to date.
Conclusions: Post-SCS NMP was successfully implemented in 11 cases, enabling the safe utilisation of grafts deemed non-transplantable using static cold storage preservation alone. The technique was user friendly, improved transplant logistics and surgeon confidence, and increased local transplant activity by 10%.
[Figure 1]
PT01-12 Liver Transplantation for Metabolic Liver Disease Patients: A Single-Center Experience
Yuichi Masuda, Japan

Y. Masuda, K. Yoshizawa, N. Tsuyoshi, K. Kubota, A. Shimizu, Y. Ohno, A. Mita, T. Ikegami, Y. Soejima
Surgery, Shinshu University, Japan

Introduction: Metabolic liver disease (MLD) is life threatening. The efficacy of liver transplantation (LT) for MLD patients are well reported. There are some options of surgical procedures, but a few reports of collecting data was reported from a single-center. Here we present our experiences of LT procedures including deceased donor (DD) LT, living donor (LD) LT and auxiliary partial orthotopic liver transplantation (APOLT), and outcome in those patients.
Methods: Medical records of 61 MLD adult (≧18 years old) recipients underwent LT in our institute were reviewed retrospectively. Perioperative factors were investigated. The patient survival rate was calculated.
Results: The causes of LT were familial amyloid polyneuropathy in 42, adult-onset type 2 citrullinemia in 17, glycogen storage disease in 1 and Wilson's disease in 1. The median age at LT was 37.1 (range 18.8 to 58.4) years old. All DDLT recipients received whole liver graft (n=7). In all LDLT cases (n=54), the left liver grafts were used. The median volume of graft was 392g that was correspond to 38.0% of the recipient standard liver volume (range 230 (22.1) to 580g (58.8%)). In 18 cases of those, APOLT was selected because of extremely small size of graft or expectation of future gene therapy. The 10-year survival rate of MLD recipients was 86.8%.
Conclusions: Even though a graft is relatively small, LT for MLD patients could be successfully achieved with APOLT. The 10-year survival rate of MLD recipient in our institute was thought to be satisfactory.
PT01-14 Long-term Outcomes of Preventing HBV Recurrence after Liver Transplantation for Hepatitis B Associated Liver Disease with Nucleotide and HBIG
Seong-Hwan Chang, Korea, Republic of

S.-H. Chang
Surgery, Konkuk University School of Medicine, Seoul, Korea, Republic of

Introduction: Antiviral therapy with or without HBIG is a common strategy for the prevention of hepatitis B virus (HBV) reinfection. Antiviral therapy with HBIG for lifelong was our strategy, but recently we change to discontinue HBIG after one year with those who had low serum HBV DNA levels at the time of liver transplantation and agreed to stop HBIG.
Method: We did 56 liver transplantations since June 2006. Among them, 34 liver recipients had liver cirrhosis associated with HBV, 10 with HCC and 24 without HCC. Three operative mortalities, three deaths within one year related with infection, and one follow up loss less than one year were excluded from analysis. We analyzed 27 liver transplantations retrospectively.
Result: We prevent HBV reinfection with entecavir (or tenofovir) lifelong with 7 days of daily intravenous HBIG 10,000 unit including operative day, and then once a week for next three weeks, and then once a month for one year. After then, 4000 or 6000 units per two or three months were given to maintain patients' serum hepatitis B antibody titer more than 200 mIU/mL. Median follow up period for HBV reinfection was 124.6 months. No one had reinfection till today.
Conclusions: Antiviral therapy with HBIG is an excellent prevention strategy for HBV reinfection after liver transplantation and changing to an antiviral agent only needs further research.
PT01-15 Computational Fluid Dynamics-based Assessment of Impaired Hepatic Venous Outflow after Liver Transplantation
Takashi Ito, Japan

T. Ito1, S. Ogiso1, M. Nakamura2, K. Fukumitsu1, T. Ishii1, K. Hata1, T. Masui1, K. Taura1, S. Uemoto1
1Department of Surgery, Kyoto University, Japan, 2Department of Mechanical Engineering, Nagoya Institute of Technology, Japan

Introduction: Hepatic venous outflow obstruction (HVOO) is a critical complication after living-donor liver transplantation (LDLT) potentially associated with graft insufficiency; however, modalities to detect the impaired hepatic venous outflow have not been established. This study investigated the usefulness of computational fluid dynamics (CFD) to analyze the hepatic venous outflow after LDLT.
Method: Vascular geometry was created using dicom data of computed tomography. The vein flow was simulated on a fluid analysis software and inflow condition was set based on the flow velocity measured on Doppler ultrasound. Hemodynamic parameters of the hepatic venous outflow, such as streamline and pressure gradient, were analyzed and their impacts on the post-transplant liver hypertrophy were evaluated. As a representative example, analyses for a 62-year-old female who developed HVOO 3 months after left-lobe LDLT is presented.
Result: Pressure gradient between left hepatic vein (LHV) and vena cava was estimated at 1.4mmHg on day7, and 5.1mmHg on day34 on CFD analyses, while that between middle hepatic vein (MHV) and vena cava was estimated at 1.3mmHg on day7, and 3.1mmHg on day34. A venography at 3 months revealed an LHV stenosis with a pressure gradient of 15 mmHg, treated with balloon angioplasty. Volumetric analyses showed hypertrophic rate of LHV-draining territory between day7 and day34 was only 4.37%. Whereas, that of MHV-draining territory was 38.5%.
Conclusion: CFD unveiled early and otherwise undetectable abnormalities of the hepatic venous outflow, which impaired graft liver regeneration. CFD would be useful to optimize the management of the graft liver outflow after LDLT.
[Pressure distribution on CFD analyses]
PT01-16 Effects of Reoptimization of Immunosuppressive Treatment on Donor-specific HLA Antibodies after Liver Transplantation
Kazuaki Tokodai, Japan

K. Tokodai, S. Miyagi, W. Nakanishi, A. Fujio, T. Kashiwadate, T. Kamei, M. Unno
Department of Surgery, Tohoku University, Japan

Introduction: Donor-specific antibodies (DSAs) have negative effects on short- and long-term outcomes after organ transplantation. DSAs are prevalent in patients with low immunosuppression; thus, optimized immunosuppression is preferable even in patients with stable condition after liver transplantation. However, the effect of implementing immunosuppression reoptimization for patients with low immunosuppression remains unclear. In this study, we investigated long-term changes in DSA status and the effect of reoptimizing immunosuppression on DSA status.
Methods: We retrospectively reviewed DSA status in 66 patients after liver transplantation in our center.
Results: The median duration between first and second DSA evaluation was 50 months. Of the 66 patients, 43 were positive for class II DSAs in the first evaluation. Of these patients, 30 were found to have an insufficient dose of calcineurin inhibitor, or were immunosuppression free at the time of the first evaluation. Reoptimization of immunosuppression was then conducted for 20 of the 30 patients. Among the 20 patients, DSAs detected in the first evaluation became negative in 7 patients and mean fluorescence intensity (MFI) decreased in 9 patients. Compared with patients with sustained low immunosuppression, DSA levels significantly decreased in patients with reoptimized immunosuppression (p=0.005).
Conclusion: The results of this study indicate that post-transplant reoptimization of immunosuppression improved DSA status after liver transplantation. Reoptimization of immunosuppression is considered to be especially preferable in patients with de novo DSAs, although the clinical significance of DSA negative conversion and/or MFI reduction needs to be further investigated.
PT01-17 Sense or Nonsense: Defining the Role of Routine Gallbladder Histopathology in Deceased Liver Transplantation
Philipp Kron, United Kingdom

P. Kron, I. Rajput, M. Jaklitsch, P. Lodge
St James's University Hospital, United Kingdom

Introduction: In liver transplantation donor cholecystectomy followed by histological assessment is routinely performed as part of the operation. However, the evidence on this topic is scarce. The aim of this study was to evaluate the impact of this standard of care treatment.
Methods: A single centre retrospective analysis of all gallbladder histopathologies following liver transplantation between 01.01.2007 and 31.12.2016 was performed.
Results: A total of 1012 histologies of donor gallbladders were included in this timespan. The median donor age was 47 years (range 1-79). In total 634 (63%) of the histologies were completely normal and did not show any abnormalities. 378 (37%) patients showed abnormal pathology results; 343 (33.9%) chronic cholecystitis. Of the 35 remaining gallbladders, 1 demonstrated high-grade dysplasia and one had a T1a gallbladder cancer and the rest were not significant pathologies. Those donors with normal histology had a median age of 45 years versus 50 years for abnormal histology (p < 0.05). Importantly, the recipient of the liver with T1a gallbladder cancer did not develop any signs of malignancy, although he required re-transplantation for unrelated reasons.
Conclusion: Donor gallbladder histopathological analysis in liver transplantation has been the standard of care but the role of this routine procedure has never been identified. This is an important first analysis of a significant number of donor gallbladder specimens. Based on the abnormalities detected in this single centre experience we do think donor gallbladders should routinely be send for histopathology. Further high volume studies are needed to clearly answer this question.
PT01-21 Early Experiences of Liver Transplantation in A Newly Opened Hospital
Cheon-Soo Park, Korea, Republic of

C.-S. Park, J.H. Park, D.G. Kim
Department of Surgery, Eunyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea, Republic of

Since the first human liver transplantation (LT) performed in 1963, LT has been most effective treatment for end-stage liver diseases and for selected patients with hepatic neoplasms. Herein we will report early experience of liver Transplantation in a newly opened hospital on April, 2019.
We have been operated eight LT from June, 2019 to December, 2019. In clinical features of recipients, mean age was 50.5 ± 7.7 (years), six male and two female, the causes of LT were one autoimmune liver cirrhosis (LC), three alcoholic LC and four HBV-LC with HCC. MELD score (mean) was 16.9 ± 13.2, GRWR(%) was 1.07 ± 0.22, operative time(mean) was 661 ± 161.9 minutes. Two transplanted graft was extended left lobe, five grafts were modified right graft and one was cadaveric donor whole liver graft. All bile duct reconstruction was conducted by duct to duct anastomosis. Mean post-operative hospital day was 25.6 ± 9.8 (days), and there was some morbidity.
In features of seven living donors, mean age was 29.7± 11.3 (years), six male and one female, post-operative hospital day was 15.3 ± 5.6 (days), and there was two minor bile leakage but no mortality.
A multidisciplinary approach with surgical, anesthetic, radiologic and medical departments, and wide range of administrative supports, which can be provided with institutional and foundational support, is crucial. We thought that the multidisciplinary teamwork including thorough preparation for LT is most important for which first started the liver transplant in a newly opened hospital.
PT01-22 Outcomes of Liver Transplantation in Patients with Situs Inversus
Zainab Alqaidoom, Australia

Z. Alqaidoom1,2, M. Awadh2, A. Alderazi3, A. Dhaif3
1School of Public Health and Preventive Medicine, Monash University, Australia, 2Southeast University, China, 3General Surgery Department, Salmaniya Medical Complex, Bahrain

Introduction: Situs Inversus was considered a contraindication for liver transplant in the past, due to the anatomical difficulties and the associated vascular abnormalities. Nowadays, several studies and series reported successful liver transplant in situs inversus recipients and also from donors. However, it is still rare. Therefore, we conducted a systematic review to assess the transplant techniques and their outcomes in situs inversus individuals.
Methods: We searched through four database engines; PubMed, EMBASE, Web of Science, and CINAHL. Articles were included if they reported our main outcomes of surgical technique, morbidity, and mortality of liver transplant in adult patients.
Results: 31 reports, including 35 situs inversus individuals, were included in this review. Of which 19 patients were situs inversus recipients, and 14 were donors. The most common reported transplant technique is orthotopic liver transplant with 180° rotation. HBV, HCV, and alcohol-related liver disease were the most common etiologies for end-stage liver disease in situs inversus recipients. The mean MELD score for the situs inversus recipients was 22 (ranged 9-36), the mean hospital stay was 19 days (ranged 7-45), and the operation time ranged from 3.5 to 11.5 hours. The overall complication rate was higher in situs inversus recipients than in patients who receive grafts from situs inversus donors 50% (9/18) and 33.3% (4/12), respectively.
Conclusion: Liver transplant in situs inversus recipients is feasible, and liver grafts from situs inversus donors are considered safe. Despite the anatomical intricacy, preoperative planning and the use of proper techniques can lead to successful outcomes.
PT01-23 Early Experience of ABO-incompatible Living Donor Liver Transplantation in Haeundae Paik Hospital
Jeong-Ik Park, Korea, Republic of

J.-I. Park, B.-H. Jung
HBP Surgery and LT, Haeundae Paik Hospital, Inje University, Korea, Republic of

Introduction: ABO-incompatible LDLT (ABOi-LDLT) could be a useful option for expanding pool of available organs. Since the introduction of rituximab in ABOi-LDLT, the incidence of AMR dropped dramatically and the paradigm of ABOi-LDLT in adult patients has changed.
Methods: We would like to present our initial experience of three cases of ABOi-LDLT. The protocol includes a single dose of rituximab (300 mg/m2) 3 weeks before transplantation, several sessions of plasmapheresis to decrease the isoagglutinin (IA) titer to ≤ 1:32, and a triple immunosuppressive regimen consisting of tacrolimus, mycophenolate mofetil, and steroid.
Results: All three patients performed a relatively large number of plasmapheresis to reach the target IA titers (16, 19, and 7 sessions, respectively). The IA titers immediately before transplantation were 32, 1024 and 128, respectively, while the peak titers during post-transplant period were 32, 128, and 32, respectively. In particular, case 2 patient has severe rebound elevation of IA titer even after administration of Bortezomib, a proteasome inhibitor that depletes plasma cells. As for this patient, we should perform LDLT at an IA titer 1:1024 with splenectomy and prophylactic intravenous immunoglobulin. Two patients (case 1, 2) are alive with no evidence of AMR until now, but one patient (case 3) died at POD51 due to hepatic artery thrombosis and sepsis.
Conclusions: Rituximab-based protocol is a cornerstone in the regimens of desensitization for ABOi-LDLT, but more study on pre-transplant target IA titer and effectiveness of pre-transplant plasmapheresis needs to be continued as seen in the present cases.
PT01-24 Long Term Outcomes of Combined Liver Kidney Transplantation in Children with Heritable Disorders
Zubir Ahmed, United Kingdom

Z. Ahmed1,2, J. Stojanovic2, P. Chandak1,2, N. Kessaris1, N. Mamode1
1Transplantation, Guy's and St Thomas NHS Foundation Trust, United Kingdom, 2Nephrology and Transplantation, Great Ormond Street Hospital, United Kingdom

Introduction: Outcomes of combined liver kidney transplantation in children remains a largely unquantified yet potentially life transforming procedure for those with heritable disease. No case series assessing the impact of the CLK on patient outcome for children solely with heritable disease is available. We therefore sought to retrospectively analyse the practice in a large London quaternary centre.
Methods: Children undergoing liver kidney transplantation from 2003 onwards were analysed. Indication for transplant graft types, graft survival and patient survival were recorded. Disease specific metabolic parameters were also recorded.
Results: 9 children underwent liver kidney transplanation of which 7/9 were combined. All grafts in CLK group were deceased donor (1 whole liver, 1right lobe, 5 left lateral segments). The mean age was 6.8 yrs. The indication was primary type 1 hyperoxaluria (n=1), Allagile (n=1) and autosomal recessive polycystic kidney disease (n=5). The median follow up was 5213 days. 1 year and 5 year liver and kidney graft survival was 100%. Mean GFR at one year was 66.6 mls/min and last follow up was 64.4mls/min. Mean AST level at last follow up was 44. One child required re transplant at five years due to chronic liver graft rejection. All current transplant grafts were functional at last follow up.
Conclusions: CLK is a safe practice in children with heritable and metabolic conditions. Excellent graft outcomes are possible. In countries where deceased donor organ pools are readily available this practice should be adopted as the mainstream of treatment.
PT01-31 Treatment with Everolimus for Bile Duct Stenosis after Liver Transplantation
Hirokatsu Katagiri, Japan

H. Katagiri, H. Nitta, T. Takahara, Y. Hasegawa, S. Kanno, A. Sasaki
Surgery, Iwate Medical University, Japan

Background: Treatment of antibody mediated rejection (AMR) in post-liver transplant management has not been established at present. In some cases, it has been reported that everolimus (EVR) inhibits worsening of chronic rejection, and there is great expectation for the efficacy of EVR for chronic rejection.
Aim: Toverify the hypothesis that use of EVR will improve the symptoms of mechanical biliary stenosis in LT recipients, which did not respond to any other treatments.
Methods: 107 recipients underwent LT from January 2007 to October 2018 were retrospectively analyzed. Biliary complications, donor specific antibody (DSA) and AMR were examined.
Results: The incidence of biliary stenosis was 16.8%. 3 cases (2.8%) were pathologically diagnosed as AMR. All of them experienced acute cellular rejection, and had poor outcome because of lack of EVR addition. DSA positive rate was 13.9% (6/43 cases). Rate of biliary stenosis in DSA positive was 83.3% (5/6 cases). On the other hand, rate of biliary stenosis in DSA negative was 16.2% (6/37 cases). EVR was used for 8 cases (7.4%), 7 of them (87.5%) had biliary stenosis, which did not respond to any other treatments. All of them could not be proved to be pathologically AMR but responded effectively to addition of EVR.
Conclusions: It is difficult to introduce EVR after pathologically proving de novo AMR. If therapeutic effect on the biliary complication is poor, chronic AMR may be present in the background. In such cases, EVR may be effective treatment.
PT01-33 Standardizing Pure Laparoscopic Donor Hepatectomy (PLDH) - Expanding the First Largest Series from Indian Subcontinent
S Srivatsan Gurumurthy, India

S. Srivatsan Gurumurthy, M. Srinivasan, N. Anand Vijai, S. Swaminathan, P. Senthilnathan, C. Palanivelu
Dept. of HPB, Minimally Invasive Surgery & Liver Transplant, Gem Hospital, India

Introduction: Even after 2 decades of experience in laparoscopic hepatectomy, data on purely laparoscopic approach for donor hepatectomy in adult living donor liver transplantation (LDLT) is limited, especially from India. We report our series of 18 cases of pure laparoscopic donor hepatectomy from India, which is the largest reported series from the country.
Method: We report our initial experience of a purely laparoscopic approach for donor hepatectomy for adult recipients to explore its potential application in the management of donors. A retrospective data analysis of 18 consecutive patients operated between Jan 2018 and October 2019 was done.
Result: There were 16 right, 1 left hepatectomy and 1 left lateral sectionectomy. The median operative time was 486 minutes (range 294-684 minutes), and warm ischemia time was 6 minutes (4-12 minutes). Estimated blood loss was 300 mL (10-850 mL) and none of the patients required intraoperative transfusion. Two patients required conversion to Lap Assisted approach, due to unfavourable biliary anatomy. 2 patients had bile leak, both requiring ERCP and stenting and there was no mortality.
Conclusion: Purely laparoscopic donor hepatectomy for adult LDLT recipients seems to be a feasible option; with careful patient selection and when performed by experienced surgeons, it may afford results comparable to the open method. Further evaluation, including long-term results, may support these preliminary findings of comparative outcomes for donors undergoing PLDH.
PT01-34 Biomarkers and Inmunohistological Characteristics in the Liver Grafts from Donors after Circulatory Death and Donors after Brain Death: A Propensity Score Matching Analysis
Victor Lopez, Spain

V. Lopez1, C. Martinez1, D. Ferreras1, J. De la Peña1, J. De La Cruz2, J.A. Pons1, F. Sanchez Bueno1, R. Robles-Campos1, P. Ramirez1
1Clinica and University Virgen de la Arrixaca Hospital, Spain, 2Group of Applied Mathematics in Science and Engineering, Spain

Introduction: Donation after Circulatory Death (DCD) is related with an additional ischemia time and higher rates of biliary complications and graft loss comparing with traditional donors (DBD). We compare histological and biological markers of DCD and DBD liver grafts
Methods: From November 2014 to December 2018 were retrospectively collected the biopsy of the retrieval and we compare histological and biological markers of DCD and DBD liver grafts. The immunohistological analysis include markers p21, TERT, caspase-3 active, HIF1A, VEGF, CD90, CD44 and COX-2. A propensity score matching (PSM) was used to match patients receiving DCD and DBD livers.
Results: Al samples analyzed were negative for VEGF, p21 and caspase-3 expression. The positive staining expression of COX-2, CD44, TERT, HIF1A and CD90 showed no statistically significant differences between DCD and DBD and with ischemic cholangiopathy. After PSM, there was a statistically significant relationship between CD90 and male donors [OR 0.26 (95% CI, 0.07-0.91)], TERT with donor sodium [OR 1.11 (95% CI, 1.02-1.2)], HIF1 with steatosis [OR 0.33 (95% CI, 0.13-0.83)] and CD44 with donor vasoactive drugs [OR 0.36 (95% CI, 0.13-1)] and GOT 1 week increase [OR 1.01 (95% CI, 1-1.03)]. The incidence of biliary complications (p=1) and ischemic cholangiopathy (p=0.35) was higher in DCD but without significance statistics.
Conclusions: In our experience, the immunohistological pattern of liver suffering between DCD and DBD was similar. In addition, the higher rate of biliary complications and cholangiopathy in DCD also does not appear to have a direct relationship with markers analyzed in the graft.
PT01-35 Influence of Controlled Donation after Circulatory Death (cDCD) on Waiting List Mortality for Liver Transplantation in the Last 10 Years: The Spanish Experience
Felipe Alconchel, Spain

F. Alconchel1,2, M. Royo-Villanova2,3, P.A. Cascales-Campos1,2, L. Martínez-Alarcón2, B. Febrero1,2, T. Nicolás-López1,2, F. Sánchez-Bueno1,2, R. Robles1,2, P. Ramírez1,2
1Hepatobiliary Surgery and Liver Transplantation, Virgen de la Arrixaca University Hospital, Spain, 2Biomedical Research Institute of Murcia IMIB-Arrixaca, Spain, 3Intensive Care Unit, Virgen de la Arrixaca University Hospital, Spain

Controlled donation after circulatory death (cDCD) provides one third of liver donors in Spain nowadays. The aim of our work is to evaluate the impact that cDCD has had on the evolution of mortality on the waiting list for liver transplant at our hospital over the last 10 years. We retrospectively analyzed liver donation and transplant activity data at our center over the past 10 years through our records and those of the Spanish National Transplant Organization (ONT). Figure 1 shows the percentages of patients on the liver transplant waiting list who were transplanted, dropped-out from the list, or died on the list during the last 10 years (2010-2019). It should be noted that in the pre-cDCD era (before 2014) the mortality rate on the list was above 20%. However, in the age of controlled-DCD (from 2014 onwards) this percentage has decreased to 6% in 2019. As for the probability of liver transplantation per year (Figure 2), it has remained in progressive ascent despite the high rate of indication for liveer transplantation in our group (69.4 pmp, year 2018), the highest in Spain.The successful introduction of the controlled donation after circulatory death program at our hospital has reduced the mortality rate on the waiting list for liver transplants by 19% in 5 years. The probability of liver transplantation per year has increased by up to 20%.Therefore, cDCD has allowed us to significantly reduce mortality on the waiting list for liver transplantation.
[Figure 1 and 2]
PT01-39 The Short-term Outcome of Salvage Liver Transplantation for Patients with Hepatocellular Carcinoma: A Propensity Score Matching Analysis
Shinichiro Nakada, France

S. Nakada1,2, M.-A. Allard1, Y. Kitano1, E. Vibert1, A. Sa Cunha1, D. Cherqui1, M. Miyazaki2, M. Ohtsuka2, R. Adam1
1Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, Université Paris Sud, France, 2Department of General Surgery, Chiba University, Graduate School of Medicine, Japan

Background: Long-term outcome of salvage liver transplantation (SLT) for a patient with hepatocellular carcinoma (HCC) is known to be associated with good results. However, some previous reports showed that SLT had higher potentials of post-operative bleeding, repeat operation, and early mortality. Though the background of SLT and PLT was different, there was no study using propensity score matching (PSM). The purpose of this study aimed to assess themorbidity of patients after SLT with PSM.
Methods: Data from 544 consecutive patients undergoing LT for HCC between 1994 and 2017 at a single center institution, were retrospectively reviewed. Fifty-six (10.3%) were submitted to SLT, and 488 (89.7%) were primary liver transplantation (PLT) as a control group. Comparisons between groups were performed using PSM.
Results: Patients with low BMI, low MELD score, low AFP, and a high number of tumors were more likely to perform SLT. After PSM, 55 SLT cases were matched to PLT controls. There is no significant difference between groups, vascular complications (p= 0.297), biliary complication (p= 0.541), intraabdominal bleeding/hematoma (p=0.170), repeat-operation(p=0.463) and early postoperative mortality (p= 0.671). As a Clavien-Dindo classification, there was also no significant difference between two groups, before and after PSM.
Conclusion: Short-term outcome of SLT were comparable with PLT after PSM.
PT01-41 Tumor Progression Pattern in Patients with Hepatocellular Carcinoma Awaiting for Liver Transplantation
Wacław Hołówko, Poland

W. Hołówko1, M. Grąt1, K. Korzeniowski2, T. Wróblewski1, K. Zieniewicz1
1Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland, 2Second Department of Clinical Radiology, Medical University of Warsaw, Poland

Introduction: Patients with hepatocellular carcinoma are at risk of tumor progression while awaiting for liver transplantation. Neoadjuvant treatment such as transarterial chemoembolization is performed with intention to extend the time without progression. The aim of this study was to evaluate the incidence of tumor progression before liver transplantation.
Methods: It was a retrospective, observational study performed on 175 patients with hepatocellular carcinoma who underwent liver transplantation. Tumor progression was defined as an increase of at least 20% in the sum of the diameters of lesions. Data on tumor morphology, alpha-fetoprotein concentration and neoadjuvant treatment were analyzed.
Results: There were 101 (57.7%) patients who developed tumor progression before liver transplantation. The progression rate was estimated for 48.6% and 74.4% after 6 and 12 months, respectively. Patients treated with transarterial chemoembolization presented significantly decreased progression rate (26.7%) in comparison to the rest of a group (73.3%; p=0.002). In multivariate analysis transarterial chemoembolization independently decreases the risk of tumor progression (OR = 0.47; 95%CI 0.23-0.95; p< 0.05).
Conclusion: Transarterial chemoembolization significantly decreases the risk of progression before liver transplantation, however further studies have to be performed to select those patients who may benefit from neoadjuvant treatment the most.
PT01-43 Hepatic Artery Thrombosis in Liver Transplantation Recipients after Neoadjuvant Therapy with Transarterial Chemoembolization
Wacław Hołówko, Poland

W. Hołówko1, M. Krasnodębski1, K. Korzeniowski2, T. Wróblewski1, K. Zieniewicz1
1Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland, 2Second Department of Clinical Radiology, Medical University of Warsaw, Poland

Introduction: Transarterial chemoembolization (TACE) prior to liver transplantation for patients with hepatocellular carcinoma may increase the risk of arterial complications after transplantation. The aim of this study was to evaluate the impact of neoadjuvant treatment with TACE on the risk of post transplant hepatic artery thrombosis (HAT).
Methods: It was a retrospective, observational study performed on 228 patients with hepatocellular carcinoma who underwent liver transplantation. The diagnosis of post transplant HAT was based on computed tomography. Factors such as treatment with TACE, number of TACE sessions, time between TACE and liver transplantation, donor age, total ischemic time, diameter of common hepatic artery in recipient, arterial reconstruction, intraoperative macroscopic artery assessment and type of arterial anastomosis were evaluated in univariate and multivariate analysis.
Results: HAT was observed in 13 (5,7%) patients. The incidence rate of HAT was 5.5% for patients after TACE and 5.9% for the rest of a group (p=0.876). The only independent risk factor for HAT was poor intraoperative macroscopic artery assessment but there was no significant intercorrelation with TACE prior to liver transplantation (0.117; p=0.116). Despite the analysis did not reveal the time between TACE and liver transplantation as an independent risk factor for HAT (OR=1.001; 95%CI 0.997-1.005; p=0.476), there was a difference in median time for patient with HAT (Me=12.0 days) and the rest of a group (Me=88.5 days; p=0.040).
Conclusion: Neoadjuvant treatment with TACE does not increase the risk of HAT, however special caution should be taken when selecting the moment of liver transplantation after TACE.
PT01-45 Does Transarterial Chemoembolization Impair Liver Function in Patients with Hepatocellular Carcinoma Awaiting for Liver Transplantation?
Wacław Hołówko, Poland

W. Hołówko1, M. Morawski1, K. Korzeniowski2, T. Wróblewski1, K. Zieniewicz1
1Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland, 2Second Department of Clinical Radiology, Medical University of Warsaw, Poland

Introduction: Transarterial chemoembolization (TACE) in patients on a waiting list may decrease liver function before liver transplantation. The aim of this study was to analyze the impact of the neoadjuvant treatment on a liver function status.
Methods: It was a retrospective, observational study performed on 225 patients with hepatocellular carcinoma who underwent liver transplantation. MELD score and ALBI score were applied to assess liver function. Laboratory findings were collected before TACE and before liver transplantation for patients with neoadjuvant treatment. Liver function for the rest of patients was evaluated before enlistment and before liver transplantation.
Results: TACE was performed for 108 (48%) patients. There was no difference in median change of MELDscore between two groups (p=0.537). Median ALBI score before TACE was -2.19 followed by -2.28 before transplantation. For the rest of patients it was -1.61 before enlistment and -1,75 before transplantation. The increase of liver function according to ALBI score was significantly higher for patients without neoadjuvant treatment (p=0.019) with median change of -0.23 and -0.06 for patients after TACE, respectively.
Conclusion: The findings showed that neoadjuvant treatment with TACE does not decrease liver function before liver transplantation, however it may limit liver function restoration on a waiting list.
PT01-47 Longer Waitlist Time Does Not Translate to Poorer Outcomes for Liver Transplant Patients with Hepatocellular Carcinoma
Siew Yen Annabelle Chow, Singapore

S.Y.A. Chow1, J.H. Law2, J.J. Ang2, J.K.H. Tan2, N.Q. Pang2, G.K. Bonney2, K. Madhavan2, W.C.A. Kow2, S.G. Iyer2
1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 2National University Hospital of Singapore, Singapore

Introduction: MELD exception points (MEP) allocated to hepatocellular carcinoma (HCC) patients on liver transplant (LT) waitlist remain arbitrary and differ between countries. We seek to determine if the current policy of allocating only 15 MEP to HCC patients disadvantages them.
Methods: A retrospective review of adult patients waitlisted for LT between January 2011 and July 2019 was conducted and their outcomes were analyzed.
Results: 176 patients were on LT waitlist, of which 87 (49.4%) had HCC. The natural MELD score of HCC patients was significantly lower than non-HCC patients (median 10 vs 18, p < 0.001). Nearly 3 times as many patients in HCC group had MELD < 15 (72.4% vs 27.0%, p < 0.001). Despite allocating 15 MEP to HCC patients, their waitlist time was significantly longer (median 8.0 vs 2.0 months, p = 0.003). Dropout rates were similar at 23.0% and 33.7% (p = 0.115) over a median interval of 7.0 (1.0 - 79.0) and 2.5 months (1.0 - 53.0) for HCC and non-HCC groups respectively. 13 (65.0%) HCC patients dropped out due to HCC progression out of criteria. 67 (77.0%) HCC and 59 (66.3%) non-HCC patients were transplanted, and their 5-year OS were similar (HCC 82.1% vs non-HCC 89.8%, p = 0.402).
Conclusion: HCC patients are waitlisted for significantly longer duration despite 15 MEP. Although LT outcomes are similar, many HCC patients progress beyond criteria due to prolonged duration on waitlist. Future studies should seek to identify subgroup of HCC patients who will benefit from additional MEP.
PT01-48 Liver Transplant Can Be Performed Safely in Adult Patients with Portal Vein Thrombosis in a Medium-sized Transplantation Centre
Guan Wei Dominic Lim, Singapore

J.H. Law1, G.W.D. Lim2, N.Q. Pang1, G.K. Bonney1, S.G. Iyer1, K. Madhavan1, W.C.A. Kow1
1National University Hospital of Singapore, Singapore, 2Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Introduction: Although the feasibility of liver transplant (LT) in patients with portal vein thrombosis (PVT) has been reported, its outcomes remain debated. Its safety is especially important in small to medium-sized LT centers with scarce organs and resources. We seek to evaluate the outcomes of patients with PVT receiving LT in our center.
Methods: A retrospective review of patients who underwent adult LT between January 2011 and January 2015 was conducted and their outcomes were analyzed.
Results: 124 patients underwent adult LT, of which 56 (45.2%) and 68 (54.8%) were living (LDLT) and deceased (DDLT) donor LT respectively. More than one-tenth had PVT diagnosed at listing (n=15, 12.1%) whereby 4 had LDLT and 11 DDLT. There was equal number of patients (n=5) with Yerdel grade 1 to 3 PVT. 12 (80.0%) had thrombectomy while 3 with grade 3 PVT (20.0%) had venous jump graft. Grade 4 PVT was considered as contraindication to LT. There was no difference in post-operative PVT recurrence (no PVT 7.4% vs PVT 13.3%,p=0.351). While re-operation was more common in PVT group (no PVT 10.2% vs PVT 33.3%, p=0.027), none were related to PVT recurrence. Median duration of follow-up for no PVT and PVT groups were 78.0 months (1.0-106.0 months) and 82.0 months (63.0-97.0 months) respectively. 5-year OS was comparable between both groups (no PVT 91.4% vs PVT 100.0%, p=0.203).
Conclusion: Yerdel grade 1 to 3 PVT does not affect LT outcomes and LT can be safely performed in patients with PVT in a medium-sized LT center.
PT01-49 Characterization of Deceased Liver Donors in a Chilean University Hospital in the Last 5 Years
Caterina Contreras, Chile

C. Contreras1, P. Rebolledo1, J.L. Quezada1, M. Dib1, P. Achurra1, E. Briceño1, N. Jarufe1, L. Cortínez2, J. Martínez1
1Department of Digestive Surgery, Pontificia Universidad Catolica de Chile, Chile, 2Department of Anesthesiology, Pontificia Universidad Catolica de Chile, Chile

Introduction: The standardization and progress of surgical techniques and postoperative care has improved the outcome of liver transplantation. However, limited access to viable allografts remains; fueling efforts to maximize existing donor pool such as the use of marginal grafts.
Objective: To characterize deceased liver donors of allografts procured by Universidad Catolica Clinical Hospital (UC), with special attention to prevalence of expanded criteria donors.
Methods: Retrospective cohort study with data obtained from a prospectively collected liver donor database. We included all liver grafts retrieved by UC from April 2015 to January 2020. Descriptive statistics were used.
Results: During the given time period, a total of 112 liver grafts were retrieved for transplantation, two of which were split liver grafts (1.8%). These 112 grafts were allocated to 109 patients, and 2 were discarded (graft discard rate 1.8%). Sixty-four percent of deceased liver donors were male, with a median age of 49 (15-72), whose causes of death were stroke (65,5%), followed by traumatic brain injury (28.2%) and other (6.3%). Mean BMI was 26.67 kg/m2 (SD 3.92). Donor/recipient compatibility was identical or compatible in all cases. Fifty-one donors were ≥ 50 years old (46.4%). Forty-five-point-five percent of grafts (n=51) met expanded criteria: 23 donors were 60 years or over, 19 had cardiac arrest and 12 had cold ischemia time over 10 hours. Three met more than one criterion. The cohort's overall success rate was 95.5%.
Conclusion: Despite using a high percentage of expanded criteria donors, our university hospital maintains a high success rate.
PT01-51 Long Term Outcomes of Abdominal Wall Closure with Eptfe - Goretex Mesh in Pediatric Liver Transplantation
Jeong-Moo Lee, Korea, Republic of

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

Background: Massive transfusion and transient portal vein clamping during liver transplantation may cause abdominal compartment syndrome (ACS) related with mesenteric congestion. Especially in pediatric cases, the risk of ACS is increased due to the large for size syndrome caused by organ size mismatch. In the area of general pediatric surgery such as correction of gastroschcisis or omphalocele, abdominal closure for correction of defect using ePTFE-GoreTex is the well-established method. The purpose of this study is to describe the ePTFE-GoreTex closure method in patients with or at high risk of ACS among pediatric liver transplant patients, and to investigate the long-term prognosis and outcomes.
Methods: From March 1988 to March 2018, 253 pediatric liver transplantation were performed in Seoul National University Hospital. We reviewed the cases who underwent abdominal closure with ePTFE-Goretex during liver transplantation retrospectively.
Results: Total 15 cases were performed abdominal closure with ePTFE-Gore-Tex graft. We usually used 2mm x 10cm x 15cm sized Goretex graft for extending abdominal cavity. Median follow up was 144.8 months, there was no ACS after transplantation, but 4 cases of the patients underwent repetitive exploration due to bleeding or vessel occlusion. In repetitive surgery, we reduced every Goretex that had already used in previous operation. There was no infectious complication related Goretex implantation.
Conclusions: It is important to select appropriate method for preventing ACS in pediatric liver transplantation. Abdominal closure using ePTFE-Goretex could be a good option for the case who have high risk factor of ACS.
PT01-52 Impact of MELD Allocation System on the Outcomes of Deceased Donor Liver Transplantation: A Single-Center Experience
Jeong-Moo Lee, Korea, Republic of

J.-M. Lee, H.S. Park, K. Hong, E.S. Han, S.K. Hong, N.-J. Yi, K.-W. Lee, K.-S. Suh
Department of Surgery, Seoul National University Hospital, Korea, Republic of

Background: From the June of 2016, The Model for End-Stage Liver Disease (MELD)-based allocation system replaced the Child-Turcotte-Pugh (CTP) score-based system for organ allocation of the liver in Korea. The aim of this study is to analyze the changes of outcomes and to describe arising issues before and after the MELD system.
Methods: From June 2014 to June 2018, 129 patients were selected from recipients who underwent DDLT in Seoul National University Hospital. Pediatric cases were excluded. Patients were divided into two groups according to the allocation system (52 in the MELD group, 77 in the CTP group).
Results: The MELD score of the two groups differed significantly (37.8±2.0 in the MELD group, 31.0±8.2 in the CTP group, P=0.001). The etiology of patients was changed difference in etiology for liver transplantation, Proportion of Alcoholic cirrhosis is increased in the era of MELD allocation system. However, proportion of hepatitis B related liver cirrhosis and hepatocellular carcinoma were decreased. Long term survival rate in CTP group was 80.1% but it was decreased to 75% in MELD group. There were no differences of the complication rate in the CTP group and MELD group (35%, 31%). No one received a DDLT for hepatocellular carcinoma.
Conclusions: The MELD allocation system distributes the liver to severely ill patients, resulting in poor performance after surgery, and as proportion of alcoholic cirrhosis increase, problems such as re-drink failure may become an issue in the future. It is necessary to adjust MELD allocation system for increasing outcomes after DDLT.
PT01-53 Perioperative Management for Liver Transplantation with DSA Positive Patients
Akiko Omori, Japan

A. Omori, Y. Kotera, S. Ariizumi, S. Yamashita, T. Kato, G. Shibuya, H. Egawa, M. Yamamoto
Tokyo Women's Medical University, Japan

Background: Liver transplantation is an accepted treatment for end-stage liver disease. Despite improvements of the surgical techniques, organ preservation methods, and immunosuppressive therapy, antibody mediated rejection is still big problem. It has been reported that the existence of donor-specific antibodies (DSA) is correlated with rejection and with an increased risk of early mortality. We described our treatment and prognosis about the patient who has undergone liver transplantation with DSA.
Methods: 16 patients among 87 patients of recipient who has undergone liver transplantation in our department from September 2011 to December 2018. In each patient, the type of DSA and the MFI were measured before liver transplantation. A high DSA titer was defined as a normalized, trimmed MFI value ≥10000. Patients received the standard immunosuppressive protocol for liver transplantation, including steroids, tacrolimus, and mycophenolate mofetil, with addition of rituximab more than two weeks before transplantation and took medication such as tacrolimus and mycophenolate mofetil one week before the transplantation. During operation, each patient underwent splenectomy.
Results: 7 patients have high titer DSA, and each patient has a desensitization method that described before. Only one patient was dead because of other disease. 9 patients are still arrived without severe rejection.
Conclusion: If the patients who has DSA was undergone right desensitization methods, we can get good survival rate.
PT01-54 Single Center Series of Liver Transplantation for Cirrhosis Complicated by Portal Vein Thrombosis or Stenosis
Aliaksei Shcherba, Belarus

A. Shcherba, S. Korotkov, I. Shturich, D. Kharkov, L. Kirkovsky, O. Rummo
Minsk Medical Center for Surgery, Transplantation and Hematology, Belarus

Portal vein thrombosis (PVT) is a known complication of liver cirrhosis with reported incidence up to 32% and the rate of LT of only 1.2%-6.6% due to surgical complexity and risk.
691 liver transplants were performed in a period of 2008-2019. The rate of LT for PVT was 6.2% (43/691). The PV reconstruction (PVR) technique depended on PVT grade, age, presence of shunts and was composed of thrombectomy (19), reno-portal transposition (8), jump and interposition graft (2), mesoportal (1), shunt-to-portal anastomosis (2) in adults and cava-portal transposition (7), confluent-portal (2), venoplasty(2) in pediatric patients.
The median age in PVR adults was compared to conventional PV anastomosis CPVA (p=0.08). Median blood loss, the rate of AKI, EAD and new onset PVT were 2000 [800; 3500] vs 1200 [700; 1700] (p = 0.06); 20% vs 15,7% (p = 0.7); 10% vs 24.5% (p = 0.3) and 10% vs 0,7% (0.07) in PVR compared to CPVA group.
The median age in PVR pediatrics was compared to CPVA (p= 0,12).
Median blood loss, the rate of AKI, EAD and new onset PVT were 150 [100; 250] vs 150 [100; 250] (p = 0.04); 9% vs 18,2% (p=0,9), 27.3% in PVR group vs 37,2% (p=1) and 10% vs 11.3% in CPVA (p =1) in PVR compared to CPVA group.
PV reconstruction is a challenging procedure in LT for PVT and associated with higher rate of complications but not mortality. The choice of PV reconstruction/thrombectomy depend on PVT grade, age, and presence of suitable shunts.
PT01-55 Fate of 500 Referrals to a Liver Transplant Surgical Unit in India. Are We Saving Enough Lives?
Naga Sudha Ashok Reddipalli, India

N.S.A. Reddipalli
Surgical Gastroenterology, Yashodha Super Speciality Hospital, Hyderabad, India

Background: Living Donor Liver Transplant(LDLT) is the mainstay of Liver Transplants(LT) in India. Data on transplant referrals and their outcomes is lacking from the subcontinent.
Material and methods: This was a retrospective analysis of 500 referrals to the LT surgery team between November 2018 to July 2019. Patient particulars, diagnosis, MELD score, contact number, referring doctor, and plan as advised by the team was noted. A universal questionnaire was answered individually by each patient or primary caretaker after a minimum waiting period of 4 weeks from the clinic or inpatient visit.
Results: LT was advised in 450(90%) patients. 45(9%) patients were lost to follow up. Predominant etiology was alcohol in 240/500(48%) and median MELD score was 24(Range 11-40). 54 out of 450(12%) eventually underwent LT. Of the 43 patients transplanted at our center there was no inpatient mortality. 231/450(51.3%)patients did not agree for evaluation. Finance was the reason 88/450(19.5%), unavailable donor in 57/450(12.7%), lack of both finance and donor in 68/450(15.1%), patient or family refusal in 18/450(4%), and preferring a different hospital for transplant in 11/450(2.4%). 77/396(19.4%) patients who did not undergo LT for various reasons died. 30/450(6.6%) patients improved on follow up and did not require LT.
Conclusions: Lack of finances and living/deceased donors are the major impediments in LT. Improvement in organ allocation and deceased donation, public awareness, wider insurance coverage and financial support from government agencies can help in reducing mortality in patients eligible for LT.
PT01-56 Liver Transplantation for Epithelioid Hemangioendothelioma (EHE) - Short and Long-term Outcomes from 30 Years' Experience
Rajendran Vellaisamy, United Kingdom

R. Vellaisamy, M. Cortes, P. Srinivasan, H. Vilca Melendez, W. Jassem, K. Menon, A. Prachalias, M. Rela, N. Heaton
Institute of Liver Studies, Kings College Hospital NHS Foundation Trust, United Kingdom

Aim: We report our experience of liver transplantation (LT) for Epitheloid hemangioendothelioma (EHE) which is an uncommon vascular tumour of liver with intermediate malignant potential. Single centre experience remains limited.
Methods: Retrospective review of 13 LT patients between 1989 to 2019.
Results: 13 patients (male 6, female 7) (paediatric 5, adult 8) underwent LT. Median age at presentation was 28 years. Median duration from diagnosis to listing was 76 days and from listing to transplant was 46 days. Presenting symptoms were jaundice, abdominal pain and distension. Most common presentation were with jaundice in children and abdominal pain in adults. 3 patients had metastases (lung 2, lymph node1) pre-transplant. Median follow-up is 108 months. 2 patient had recurrence in the graft liver. One had liver resection and the other developed lung metastases. 4 patients died. Early mortality (2m, 38m) occurred in 2 children from sepsis. Two adults died of post ERCP pancreatitis and from metastases in liver and lungs respectively. 3 patients with pre-transplant metastases did not have disease progression. Overall mean survival is 222 months. The 1, 5, and 20-year overall survival is 92%, 83%, and 66% respectively. The 5 and 20-year disease progression free survival is 90% and 72% respectively.
Conclusion: Patients with EHE even with low volume metastases represent excellent candidates for transplant with long term survival. Disease recurrence can occur in the graft as late as 181 months post-transplant. Children who had shorter time interval between diagnosis and transplant had poor survival.
PT01-58 Is There a Difference with Aged Grafts?
Magali Chahdi Beltrame, Argentina

M. Poupard, M. Chahdi Beltrame, E.G. Quiñonez, J.P.S. Duran Azurduy, M.L. Del Bueno, J.G. Cervantes, M.E. Lenz Virreira, F.J. Mattera
Hepatobiliar Surgery and Liver Transplantation, Hospital el Cruce, Argentina

Introduction: Donors for liver transplantation are accepted beyond “optimal” due to grafts shortage. We aim to analyze our results stratifying our donors by age.
Methods: Retrospective study: liver transplants from 2013 to 2018. Groups according donor's age: 1 (< 20); 2 (20 - 39), 3 (40 - 59) and 4 (> 60 years old). Statistical analysis with a significance level < 0,05.
Results: n=265 liver transplants, Group 1:41, 2:77, 3:106 and 4:41. Most frequent death diagnosis were stroke (53%), prevalent in older donors, and head injury (37%) in younger ones (p< 0,001). 68% of donors had overweight or obesity, being higher in groups 3 and 4 (p=0,006). There were no differences in liver enzymes, sodium, use of vasopressors, or cardiac arrest. 91% of splits were from groups 1 and 2 (p< 0,001). Hepatorenal transplants used grafts only from group 1 and 2 (p< 0,001). Analyzing recipients age: older livers for older patients (p=0,007). The mean cold ischemia time was longer in group 1 (520 min), 2 (477), 3 (429) and 4 (410) (p< 0,001). No significant differences in the liver enzymes peak, days of hospitalization, morbidity or mortality. There weren't cases of primary graft failure in groups 1 or 2, most were in 3 (p=0,039). Graft survival and overall survival did not yield significant results, though in group 4 overall survival at 3 and 5 years was lower (p=0,053).
Conclusion: The use of suboptimal donors is feasible with similar results but an adequate selection of the recipient is also essential.
PT01-60 Liver Transplantation for the Carryover Patients who Have the History of Multiple Laparotomies Including Kasai's Operation
Shigehito Miyagi, Japan

S. Miyagi, K. Tokodai, W. Nakanishi, A. Fujio, T. Kashiwadate, T. Kamei, M. Unno
Department of Surgery, Tohoku University, Japan

Objective: Forty-five years passed from Kasai's operation announcement for biliary atresia. And the adult liver failure cases so-called “the carryover cases after Kasai's operation” have increased. In these cases, there are many patients who underwent polysurgery. In the polysurgery cases, liver transplantation is occasionally difficult. It is reported that there are many complications which is caused by severe cholangitis, hepatic portal regional inflammation, and adhesion. We investigated the complications of our polysurgery cases including “the carryover cases after Kasai's operation”.
Methods: From 1991 to 2019, we performed 198 cases of liver transplantation. We investigated the results of our carryover cases after Kasai's operation (Transplantation was performed over 16 years old) (n=22). Furthermore we investigated risk factors of complications.
Results: On five years overall survival, there were no significant differences between “the carryover cases after Kasai's operation” and the others (81.8%vs81.2%). The carryover case after Kasai's operation was not found to be the risk factor of any complications. But polysurgery was the risk factor for portal stenosis and biliary stenosis identified on our univariate analysis. We analyzed the relationship between biliary stenosis and the frequency of laparotomy using an ROC curve. The analysis showed that the cutoff point (maximum point of sensitivity plus specificity) was over two times of laparotomy before transplantation.
Conclusion: In our study, the carryover case after Kasai's operation was not found to be the risk factors of any complications. But the polysurgery case was identified to be the risk factors of portal vein stenosis and biliary stenosis.
PT01-61 Impact of Preservation Solution on Liver Transplantation Outcome: Comparative Analysis of HTK and IGL1
Valerio Lucidi, Belgium

J. Navez1, D. Germanova1, A. Putignano2, A. Lemmers2, M. Pezzullo3, R. Surin4, B. Ickx5, T. Gustot2, V. Lucidi1
1Hepatobiliary and Transplantation Surgery - Department of Abdominal Surgery, Université Libre de Bruxelles ULB Hôpital Erasme, Belgium, 2Gastroenterology, Hepatopancreatology and Digestive Oncology, Université Libre de Bruxelles ULB Hôpital Erasme, Belgium, 3Radiology, Université Libre de Bruxelles ULB Hôpital Erasme, Belgium, 4Transplantation Coordination, Université Libre de Bruxelles ULB Hôpital Erasme, Belgium, 5Anesthesiology, Université Libre de Bruxelles ULB Hôpital Erasme, Belgium

Type of preservation solutions (PS) used for organ procurement and static cold storage before liver transplantation (LT) changed over time and are currently in our center mostly HTK and IGL1. Large registries analysis showed a shorter graft survival with HTK.
Aim: compare LT outcomes according to PS used.
Patients undergoing primary LT between 2013 and 2018 with grafts preserved with HTK or IGL1 solutions were retrospectively reviewed analysing postoperative short and long-term outcomes.
190 patients underwent a first LT, using IGL1 (n=107) or HTK (n=83). Recipients baseline characteristics were similar between both groups whereas HTK group had significantly more national allocation and higher median DRI and ET-DRI scores compared to IGL1 group. HTK had significantly higher rates of early allograft dysfunction (EAD) compared to IGL1 according to Olthoff (66 vs 55% p=0,033), Dhillon (35 vs 21% p=0,046) and MEAF>7 (18 vs 9% p=0,058) definitions. HTK had a significantly higher rate of non-anastomotic biliary strictures (NAS) compared to IGL, respectively 21% and 9% (p=0,042). The 3-year graft survival was higher in IGL1 group (83% vs 69%, p=0.025). At multivariate analysis, male gender, DCD donors, HTK solution and CIT >600 minutes were independent risk factors associated with NAS. Independent risk factors of graft loss were Donor age > 65 years and HTK use. The analysis after propensity score matching showed the same results than in the global cohort of patients.
Conclusions: HTK showed to be an independent risk factor of NAS and graft loss compared to IGL1 PS after primary LT.
PT01-62 Late Re-transplantation of the Liver in Adulthood Following Successful Paediatric Transplantation'
Hassaan Bari, United Kingdom

H. Bari, T. Perera
The Liver Unit, University Hospital Birmingham NHS Trust, United Kingdom

Introduction: The survival outcomes of paediatric liver transplantation (LT) have improved from 30% in the 1970's to over 90% in the current era. Therefore a huge number of paediatric LT recipients are reaching adulthood. Non-compliance, chronic rejection and vascular related complications are common reasons for late allograft failure after a successful paediatric LT.
Methods: In this case series we specifically reviewed the outcomes of 11 patients who underwent a successful paediatric LT and underwent re-transplantation as an adult, due to primary graft failure at Queen Elizabeth Hospital Birmingham, UK.
Results: The mean age at the time of primary LT was 7.3 (+6.2) years and the most common indication was biliary atresia (36.4%). Chronic rejection was the most common reason for primary graft failure (77%) followed by hepatic artery thrombosis. The mean graft survival after paediatric LT was 13.1 (± 4.4) years. Re-transplantation of liver as adults was performed at a mean age of 23.3 (+4.2) years. Vascular related complications were observed in 36% of patients and overall postoperative morbidity rate was 88.9%. After re-transplantation the median graft survival was 34 months (2-91 months). There was only 1 ninety-day mortality. One, three and five year survival rates were 82%, 73% and 73% respectively. A third transplant was needed in 18% of patients.
Conclusion: Re-transplantation of liver in paediatric patients as adults is technically very challenging. High morbidity and mortality rates are not unexpected as these patients are already immunosuppressed and undergoing a very complex vascular and biliary reconstruction.