Poster
Transplant 		  
PT02 Transplantation: Living Donor (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PT02-02 A Proposed Predictive Model for Hyperperfusion Syndrome After Living Donor Liver Transplantation Using Platelet Count and Portal Vein Flow as Surrogates for Portal Pressure Measurement
Jeffrey Samuel Co, Philippines

J.S. Co1, C.-C. Lin2, C.-C. Yong2, C.-C. Wang2, C.-L. Chen2
1Surgery, Chinese General Hospital and Medical Center, Philippines, 2Kaohsiung Chang Gung Memorial Hospital, Taiwan, Republic of China

Background: Graft hyperperfusion syndrome (HPS) is a deterrent to transplantation using
partial grafts. Numerous risk factors were described but no predictive model exists. Thrombocytopenia early after LDLT mainly occurs secondary to graft/splenic sequestration, a product of Portal vein pressure (PVP). Post-operative Portal vein flow (PVF) monitoring unlike PVP, measures inflow, does not directly reflect sinusoidal pressure and predict graft dysfunction secondary to HPS. This study aims to determine whether post-LDLT platelet count (PC) can serve as a biomarker for PVP and present a predictive model for HPS.
Methodology: A single-center retrospective analysis of 757 consecutive adult-to-adult LDLTs from July 2010 to January 2018. Postoperative liver function, platelet count and graft hemodynamics recorded on days 1,3,5,7 and 14. Development of HPS, includes either delayed graft function (DGF) or small-for-size syndrome(SFSS). Correlation analysis and ROC analysis were done to determine cut-off points.
Results: 201 patients (29%) developed HPS. PC correlated with PVF (p< 0.001,B -0.01) and HPS (p< 0.001). PC was a better predictor (R2 0.02vs0.003 compared to PVF. PC of 67,000 yielded and PVF of 100mL/min/100g on POD5 79% and 82% sensitive rspectively. Combining PC+PVF gave a logistic model “logit (HPS)=-2.19+PC+0.92 (PVF)” with PPV of 43%, significantly higher than PC alone(23%,p< 0.001) and PVF alone (22%,p=0.001).
Conclusions: PC after LDLT is a practical surrogate for PVP monitoring and can guide inflow modulation post-operatively. Combining PC+PVF in a predictive model significantly increases its predictive value and hence, when validated, can be used to guide clinicians in caring for recipients. This model also has the potential to monitor effectivity of inflow modulation strategies.
PT02-03 Large Venous Outflow Reconstruction Using Daron Y Graft as Common Orifice of Middle Hepatic Vein and Graft Right Hepatic Vein for Modified Right Liver Graft
Eun Jeong Jang, Korea, Republic of

E.J. Jang, K.W. Kim, S.H. Kang
Division of Liver Transplantation and Hepato-Biliary-Pancrease Surgery, Department of Surgery, Dong-A University Medical Center, Korea, Republic of

Purpose: The reconstruction of the vascular outflow tract of partial liver grafts has received considerable attention in the past, especially in the setting of right liver grafts with undrained segments. Hepatic venous outflow reconstruction is an important factor for successful LDLT outcome. The aim of this report was to introduce Large Venous Outflow Reconstruction technique using Daron Y graft as common orifice of MHV and graft RHV.
Methods: We compared clinical outcomes with two reconstruction techniques through retrospective review of 46 LDLTs using right lobe grafts at our institution from Nov 2013 to Nov 2019; group I (n = 29) received separate venous outflow anastomosis between MHV reconstructed using various materials and RHV, group II (n = 16) received Large Venous Outflow Reconstruction using Daron Y graft as common orifice of MHV and RHV.
Results: The MELD, GRWR and graft volume were 13, 1.1, 723g in group I, 17.4, 1.0, 969g in group II. The 1, 3, 6-month patency rates of MHV in both groups were 100, 89.3% (p>0.24), 93.8, 51.9% (P>0.004), 66.7, 24.0% (P>0.01) respectively. RHV stent insertion in both groups occurred 2, 0 cases. Especially, MHV stent insertion did not occurred in both groups during follow-up period.
Conclusion: Although small cases, our Large Venous Outflow Reconstruction technique using Daron Y graft as common orifice of MHV and graft RHV could be an effective method of overcoming technical difficulties and the outflow disturbance in right lobe LDLT without complex bench work to create large outflow.
PT02-04 Importance of Synchronized MRCP and Intraoperative Cholangiogram in Donor Liver Transplantation: Indonesian Single Centre Experience
Vania Myralda G Marbun, Indonesia

V.M.G. Marbun, T.J. Lalisang
General Surgery - Digestive Division, Universitas Indonesia, Indonesia

Evaluations of donors' biliary anatomy in LDLT are obtained from MRCP and IOC. Bile leakage as one of the important complications can be minimised by detail acknowledgment of biliary anatomy by combining MRCP and IOC. This study aims to review donors' biliary anatomy and the impact of the acknowledgment to technique and duration.
This single centre retrospective study included 46 adult-to-pediatric and 7 adult-to-adult LDLTs performed in Cipto Mangunkusumo Hospital from 2010-2019. All patients were performed MRCP then synchronised with IOC. All results were classified by Huang Classification. Demographic data, surgical technique, duration, and radiologic discrepancy were collected.
There are 34 cholangiographies out of 53 LDLTs. No biliary complications detected. Forty-nine donors underwent left-lateral sectionectomy and 4 right hepatectomy. Operative duration ranged from 270-600 minutes. The frequency of each type on MRCP/IOC are as follows: Huang A1 40,5%/35,1%; Huang A2 37,8%;37,8%; Huang A3 13,5%/18,9%; Huang A4 5,4%/8,1%; and Huang A5 2,7%/0. Huang A1 has the shortest operative duration and the least blood loss (70cc). Huang A3 has the longest operative duration with the most blood loss (900cc). Discrepancy were found in 6 patients of which 2 underwent longest operative duration and lost the most blood.
Synchronised MRCP and IOC decrease operative duration therefore associated with better outcome. Low discrepancy showed that surgeon does not require nephrotoxic contrast media used in IOC hence reducing surgical duration except for rare cases like Huang A4 and A5 to avoid ligation of major intrahepatic duct.
PT02-06 Pure Laparoscopic Donor Hepatectomy in Pediatric Living Donor Liver Transplantation: An Appraisal of the Safety and Efficacy of the Procedure
Wan-Joon Kim, Korea, Republic of

W.-J. Kim1, K.-H. Kim2, H.-D. Cho2, J.-M. Namgoong2, S. Hwang2
1Korea University Guro Hospital, Korea, Republic of, 2Asan Medical Center, University of Ulsan College of Medicine, Korea, Republic of

Objective: This study aimed to assess the safety of this procedure in children, including surgical complications and survival outcome following LDLT, to evaluate the effectiveness of open donor hepatectomy versus pure laparoscopic donor hepatectomy in a high-volume LDLT center.
Methods: The medical records of 107 patients (aged ≤17 years) who underwent ABO compatible LDLT from May 2008 to June 2016 were analyzed. Of 107 patients, 76 underwent open donor hepatectomy and 31 underwent pure laparoscopic donor hepatectomy. To overcome bias from the differing distribution of co-variables among patients in the two study groups, a 1:1 propensity score matching analysis was performed using the nearest-neighbor matching method.
Results: The mean follow-up period was 92.9 months in the open group and 92.7 months in the laparoscopic group. The length of post-operative hospital stay of the donor was statistically shorter in the laparoscopic group than in the open group. The overall surgical complication rate did not differ between the groups. The 1-, 3-, and 5-year overall survival rates were 93.6%, 93.6%, and 93.6% in the open group and 96.8%, 93.6% and 93.6% in the laparoscopic group, respectively.
Conclusions: Laparoscopic hepatectomy may be more beneficial for the donor, and the use of laparoscopic methods on the donor does not adversely affect the recipient's outcome. Thus, laparoscopic hepatectomy is a safe, feasible, and reproducible procedure for pediatric liver transplantation.
PT02-07 Osteopenia Predicts Posttransplant Survival among Living Donor Liver Transplant Recipients
Takeo Toshima, Japan

T. Toshima, T. Yoshizumi, N. Harada, S. Itoh, K. Takeishi, S. Yoshiya, T. Ikegami, M. Mori
Department of Surgery and Science, Graduate School of Medicine, Kyushu University, Japan

Introduction: Osteopenia, loss of bone mineral density (BMD), was recently identified to be independently associated with early marker of deconditioning that precedes sarcopenia. However, little evidence about the prognostic value of osteopenia in patients undergoing LT has been reported. The aim of this study was to clarify the impact of osteopenia as the risk factor for mortality after living-donor liver transplantation (LDLT)compared with already-reported predictors in a large cohort of Japanese patients with liver cirrhosis.
Methods: Data were collected retrospectively for all consecutive 547 patients who underwent LDLT for decompensated liver cirrhosis at our institutionbetween January 2001 and Nobember 2019. BMD was evaluated with computed tomographic measurement of pixel density in the midvertebral core of the 11ththoracic vertebra by computed tomography. Data related to clinicopathological parameters and prognosis were analyzed.
Results: The median value of BMD was 171.6 Hounsfield units (HU), and osteopenia was identified in 251 (45.9%) of 547 recipients. The overall survival of the patients with osteopenia was significantly lower than the patients with non-osteopenia (P-value< 0.001; 5y, 71.5% vs. 89.7%).In addition to the other predictors, such as preoperative admission in intensive/high care unit (ICU) (HR 2.268, P=0.029) and no splenectomy during LT (HR 1.991, P=0.001), osteopenia (HR 3.029, P=0.001) was independent risk factors for mortality after LDLT by multivariate analysis.
Conclusion: Preoperative osteopenia was independently associated with post-LDLT mortality among patients with decompensated liver cirrhosis.Improving osteopenia with preoperative rehabilitation or medical therapy may improve post-LDLT survival.
PT02-09 Feasibility Assessment in Animal Models for Peritoneum Use as Interposition Vessel Graft Substitutes during Living Donor Liver Transplantation
Seok-Hwan Kim, Korea, Republic of

S.-H. Yoon, S.-H. Kim, I.-S. Song, G.-S. Chun, S.-J. Han
Surgery, Chungnam National University Hospital, Korea, Republic of

Purpose: Most of the grafts used as interposition conduits for the middle hepatic vein (MHV) in living donor liver transplantation (LDLT) have been allografts and autografts. Recently, peritoneum has been used for vessel substitutes during surgery. Thus, we performed animal lab tests to assess the feasibility of interposition vessel graft substitutes for MHV.
Methods: The inferior vena cava was replaced in three dogs and three pigs with autologous peritoneal vessel graft. After 28 days, patency rate, outer and inner diameter, intimal thickness, histology, and immunohistochemistry were evaluated according to interposition grafts.
Results: The vessel grafts made of the peritoneum were all animals at postoperative week 4. The outer diameter of the anastomotic site at four weeks was 8.41±0.37 and 7.41±0.86 mm in before surgery and after four weeks, respectively. The inner diameter of the interposition graft at four weeks was 7.90±0.23 and 6.33±0.68 in before surgery and after four weeks, respectively. In histologic findings, the intima of the anastomotic site was thickest in all animals. The proliferation of smooth muscle cells was most severe in the anti-alpha-actin antibody test at the anastomosis site. On the inner side of the peritoneum, endothelial cell migration was found over whole segments.
Conclusion: Our data implicate that the use of peritoneum as interposition vessel grafts are feasible for MHV reconstruction in LDLT.
Keywords: Living donor liver transplantation, Middle hepatic vein, Allograft, Peritoneum
PT02-10 Randomised Controlled Trial to Study the Outcome of Intravenous Phosphate Supplementation in Live Liver Donors (LLD) - Results of an Interim Analysis
Vivek Rajendran, India

V. Rajendran, V. Pamecha, S. Sasturkar, P. Sinha, N. Mohapatra, N. Patil
Liver Transplant and HPB Surgery, Institute of Liver and Biliary Sciences, India

Introduction: Hypophosphatemia is a common phenomenon after hepatectomy. Current literature is not clear regarding its consequences and the role of perioperative phosphorous supplementation.
Methods: Between January 2019 and December 2019 out of 68 consecutive LLDs ; 6 did not meet the inclusion criteria. 62 LLDs were randomized (open label); 30 in intervention arm to receive phosphorous supplementation and 32 in the control arm. The primary outcome was to see the effects on the rate of Post hepatectomy liver failure (PHLF) and postoperative complications. Secondary outcomes were to see the trend of phosphorous levels and the normalization of liver function parameters, length of stay.
Results: Baseline characteristics, operative and graft parameters were comparable between the two groups. The overall incidence of hypophosphatemia was 74.1% (66.6% in intervention arm and 81.25% in control arm; p=0.126). Post-operative complications were not significant between both the groups (20% in intervention arm and 15.62% in control arm; p=0.569). In the whole cohort there was only one major complication (Clavien Dindo 3a) in the intervention arm. Nine patients in each group developed grade A PHLF according to the International Study Group on Liver Surgery (ISGLS) criteria (p=0.689). The bilirubin and alkaline phosphatase were marginally higher on days 4 to 6 and day 7 respectively in the intervention arm.
Conclusion: In our interim analysis from the randomized trial routine phosphorous supplementation does not prove beneficial in reducing post-operative complications or speeding the recovery.
PT02-11 Evolution and Outcome of First 100 Robotic Donor Hepatectomy
Yasir Alnemary, Saudi Arabia

D. Broering, Y. Alnemary, Y. Elsheikh
Organ Transplant Center, King Faisal Specialist Hospital & Research Center, Saudi Arabia

Minimal invasive liver donor surgery was established as a feasible technique with comparable outcome to open liver donor surgery that was mainly for left lateral sectionectomy and left lobe resection. The limitation of conventional laparoscopy was clear in the right hepatectomy due difficult maneuvering and accessibility. Robotic approach was induced as an alternative to conventional laparoscopic approach. Few Paper was published with limited number of cases. Here we present own experience in Robotic Liver Donor Surgery in King Faisal Specialist Hospital and Research Center which the largest number of cases up to our knowledge. A total of 100 Robotic liver resection was carried from November 2018 to October 2019. Male donors 72 and female 28. Median age 27 years. Left lateral was 38, left 19 and right 43. Average hospital stay was 4 days. No mortality was recorded nor conversion. Morbidity only 8 patients mainly in the left and right lobe group. Two bile leak in the right lobe donors and one patient in the left lobe. Three patient had wound hematomas at the extraction incision (Pfannenstiel) incision, one in each group. Over all graft survival was 93%. Here was can say Robotic donor hepatectomy is safe with comparable result to open surgery with better post-operative pain and shorter hospital stay and better cosmesis. Reproducibility and learning carve need further evaluation
PT02-19 Surgical Techniques and Results for Totally Laparoscopic Donor Hepatectomy
Hiroyuki Nitta, Japan

H. Nitta, T. Takahara, Y. Hasegawa, H. Katagiri, S. Kanno, A. Umemura, Y. Akiyama, K. Otsuka, A. Sasaki
Iwate Medical University, Japan

Background: Progress in surgical techniques and the development of surgical devices mean that donor hepatectomy can now be performed.
Objective: To assess the feasibility and short-term outcomes of totally laparoscopic donor hepatectomy (TLDH).
Material and methods: Between January 2007 and December 2018, we performed 95 living donor liver transplantations. TLDHs was performed in 29 of the 95 donors.
Surgical technique: The pneumoperitoneum pressure was 10 mmHg. The right lobe graft was 6 ports, the left lobe and the left lateral lobe grafts were 5 ports. After liver mobilization, the right or left Glissonean pedicle was secured, ICG was injected intravenously (2.5 mg), and the transection line was confirmed. Parenchymal transections were performed by Clamp-Crushing method using the Pringle maneuver, after which the artery, portal vein, and bile duct were isolated. The bile duct was confirmed with intraoperative ICG fluorescence imaging and preoperative DIC-CT. The hepatic vein was dissected using Powered ECHELON FLEX 7.
Results: TLDHs were completed for 27 patients (93%). The median age was 35 years. Of the 29 TLDHs, 15 were right lobe grafts, 12 were left lobe grafts and 2 were left lateral lobe grafts. The median operating time was 422 minutes (range: 283-605 minutes), and the median blood loss was 59 mL (range: 21-2950 mL). There were no perioperative deaths or reoperations. Three patients (15%) experienced postoperative complications. The median postoperative hospital stay was 8 days (range: 6-16 days).
Conclusions: TLDH is a feasible and acceptable short-term solution that uses suitable surgical devices and techniques.
PT02-20 Examination of Usefulness of PELD Score for Pediatric Living Donor Liver Transplantation
Atsushi Fujio, Japan

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

Introduction: The PELD score is used for children younger than 12 years, but its usefulness has not been well reported. Thus, we examined whether the PELD score affects short-term and long-term outcome.
Methods: Of the 85 cases of pediatric living donor liver transplantation (PLDLT) performed from July 1991 to August 2020, 58 cases in which PELD scores could be calculated retrospectively using medical records. Of these, group A with a PELD score of less than 10 (n=34) and group B (n=24) with a score of 10 or more were compared.
Results: In 80% of all cases, the primary disease was biliary atresia. At the age PLDLT, group B was significantly younger than group A. Group B had significantly higher bleeding volume per body weight and intraoperative transfusion volume. Group B had a longer postoperative hospital stay and a lower overall survival rate than Group A, although this difference was not statistically significant. Postoperative rejection was common in group B. Five patients died postoperatively during the observation period., but there was no clear association with PELD score.
Conclusion: In PLDLT, surgery tends to be performed before progression to end-stage liver failure. Especially for patients under one year old, jaundice after Kasai surgery often prolonged, and the PELD score tended to be relatively low. The PELD score seemed to have some usefulness in short-term outcomes. Although, there was no significantly difference in long-term outcome.
PT02-21 Adult-Adult Liver Living Donor after Bariatric Surgery. First Report of 3 Cases
Gabriela Ochoa, Chile

G. Ochoa1, C. Marino1, E. Briceño1, E. Fernandes2, J. Martinez1, N. Jarufe1, M. Dib1
1Digestive Surgery, Pontifica Universidad Católica de Chile, Chile, 2Transplant and HPB Surgery, Federal University of Rio de Janeiro, Brazil

Introduction: The increasing prevalence of bariatric surgery (BS) and the use of living donors for liver transplantation (LDLT), could potentially face us with donors with this surgical history. Due to association between obesity and non-alcoholic liver disease, we must beware of some level of liver damage. Furthermore, it's been demonstrated that BS decreases NASH progression and reverts simple steatosis cases.
Methods: Retrospective analysis of patients with previous BS, who underwent right donor hepatectomy for LDLT at Catholic University Clinical Hospital. The information was obtained from clinical reports and telephone interviews. Analysis with descriptive statistic.
Results: Case 1: 53 years-old male, who underwent laparoscopic sleeve gastrectomy (LSG) in 2013 for BMI 33,1. In 2016, before hepatectomy, his BMI was 21,5. Normal liver function tests. Case 2: 46 years-old female, she underwent LSG(2009) and conversion to gastric bypass (2011) for severe obesity, BMI max 39,7. In pre-transplant study to become a donor BMI was 35(2016). Liver biopsy without steatosis and normal liver function tests. Case 3: 53 years-old female, LSG performed (2013), BMI max 31,5. Normal preoperative study with BMI 24,2 (2016). The three patients underwent successfully to right donor hepatectomy. No complications were observed and postoperative trend of liver function tests were in expected ranges. No transfusion requirements, mean operative time was 300 minutes, hospital stay 6,3 days, with adequate liver function in the recipients.
Conclusion: The three patients underwent successfully to right donor hepatectomy. No complications were observed and postoperative trend of liver function tests were in expected ranges.
[AST progression in donors]
PT02-23 No-touch En-bloc Total Hepatectomy Technique in Living-donor Liver Transplantation for Hepatocellular Carcinoma
Young-In Yoon, Korea, Republic of

G.-S. Jeong, Y.-I. Yoon, G.-C. Park, D.-B. Moon, S.-G. Lee
Department of Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Korea, Republic of

Although the survival benefit in patients with early HCC who underwent LDLT has been confirmed in clinical series, some studies suggested that LDLT has a higher HCC recurrence rate than DDLT. Their argument is that scrupulous dissection and mobilization of the liver might increase the possibility of tumor capsule violation or tumor dissemination through the hepatic veins. [51] To minimize these concerns, our institution, the Asan Medical Center, has its own surgical strategy named “No-Touch en-bloc total hepatectomy”.
The operation of Lt. approach is performed as following sequence. Without hepatic mobilization, we first performed Hilar dissection & division. Then, the Liver was mobilized from Left & Caudate lobe, and HVs were divided. The Rt. Lobe was mobilized as a final procedure of Total Hepatectomy.
No-touch technique has been performed in 61 patients. 93% of them underwent Pre-LDLT treatment, and TACE was the most common treatment modality. Surgical resection of HCC comprise the 18%. After LDLT using No-touch technique, In-hospital mortality was absent. The 5-Year Recurrence free survival was 44%. However, the Overall survival was Extraordinary high, 80.5%.
The no-touch en bloc method can decrease manipulation of the native liver during dissection of the retrohepatic short hepatic veins, and can be suggested as a optimal surgical technique which can be minimized tumor spread by surgical manipulation for patients with advanced hepatocellular carcinoma to improve long-term oncological outcomes in LDLT.
PT02-24 A Case Report on Tacrolimus Induced TTP and Early Use of Everlimus as Immunosuppressant in Pediatric Living Donor Liver Transplant
Rajshree ., India

R. .
Liver Transplant and HPB Surgery, Apollo Hospital, Hyderabad, India

Objective: In this case report ,we describe our experience with Tacrolimus induced TTP in pediatric LDLT and early use of Everolimus as immuosupression.
Method: Eight year old male child with DCLD due to cholesterol ester storage disorder Underwent LDLT .POD5 there was raised in bilirubin and thrombocytopenia(2.2 lakh to 20,000 /uL) ,elevated LDH (1660U/L ) and PS showed schistocytes (5-6%) F/S/O TTP .Patient developed seizures .MRI brain showed F/S/O PRESS. Tacrolimus was withheld .Patient was started on Retuximab therapy and he underwent 5 cycles of plasmapheresis. Gradually LFT's and Blood pictures normalized and patient was discharged on POD20.
Thirteen year old male child presenting with cryptogenic cirrhosis underwent LDLT. POD 10 he developed seizures and hematuria. NCCT brain showed water shed area with infarcts. POD16 patient had elevated bilirubin , Thrombocytopenia ,PS showed Schistocytes .Patient underwent 3 cycles of plamapheresis.LDH and Schistocytes levels reduced .However we lost the child to sepsis on POD 30.
Results: Diagnostic criteria for TTP include Severe thrombocytopenia30 X 10 9/L, Elevated LDH, Microangiopathic Hemolytic anemia,Schistocytes on the blood smear. Clinical presentation includes Brain 60% stroke, Heart ischemia 25%, Mesenteric ischemia 35% and Hematuria. Treatment includes plasmaphersis, steroids and Rituximab. Organ transplantation associated TTP is not the result of an immune-mediated ADAMTS13 deficiency and has the Worst prognosis.
Conclusion: Very few cases of post LDLT with TTP has been mentioned in literature review. To best of our knowledge this is the only case in which Everolimus has been used as immunosuppressant early post op period in TTP.
PT02-26 Minimally Invasive Living Donor Right Hepatectomy: Initial Experience in a Southeast Asian Transplant Center
Guan Wei Dominic Lim, Singapore

D.G.W. Lim1, J.K.H. Tan2, J.H. Law2, N.C.H. Tan2, N.Q. Pang2, G.K. Bonney2, I.G. Shridhar2, K. Madhavan2, A.W.C. Kow2
1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 2Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, National University Hospital Singapore, Singapore

Introduction: While laparoscopic left lateral sectionectomy is increasingly adopted in pediatric donors, laparoscopic donor right hepatectomy (LDRH) is only performed in a small number of highly experienced centers. We report our initial experience with LDRH as a medium-sized liver transplant center.
Methods: Retrospective analysis of living donor adult liver transplantations (LDLT) between January 2018 and December 2019 was conducted. A total of 25 LDLTs were performed, of which 7 were LDRH. Patients with anatomical variation seen on pre-operative imaging were excluded from LDRH. All cases performed were without the middle hepatic vein.
Results: Amongst LDRH cases, 3 (42.9%) were performed via laparoscopic-assist while the remaining cases (57.1%) were pure LDRH. There were 4 males (57.1%) in this group, and the median age was 41 years old (29-53 years old). Most patients (57.1%) had a body mass index of less than 25kg/m2. Median graft volume was 798mls (622-1115mls), while the median total liver volume was 1364mls (949-1728mls). Median operative time was 435 minutes (391-592 minutes) and estimated median blood loss was 300 mls (150-900 mls). The first two cases in this series were planned conversions, while the other was due to short hepatic vein bleeding. There were no post-operative morbidity and mortality reported and all patients were discharged within the first week after surgery (4-7 days).
Conclusion: LDRH is safe and feasible in a medium-sized liver transplant center. Careful case selection and planned conversions can mitigate the initial steep learning curve. Larger sample size and long-term follow up data is required.
PT02-30 Living Donor Hepatectomy Using Minimal Incision: An Experience of Consecutive 63 Cases by a Single Surgeon
Dong-Hwan Jung, Korea, Republic of

D.-H. Jung, B.-G. Na, H.-D. Cho, Y.-I. Yoon, K.-H. Kim, S. Hwang, D.-B. Moon, C.-S. Ahn, S.-G. Lee
Surgery, Ulsan University and Asan Medical Center, Korea, Republic of

Introduction: Living donor hepatectomy (LDH) is performed widely as a part of living donor liver transplantation. The type and length of incision have been considered important because of the quality of life, such as the cosmetic effect. We describe herein the minimal incision for LDH to evaluate the safety and feasibility.
Methods: We enrolled 63 consecutive cases of donor hepatectomy using a subcostal or upper midline minimal (9-12cm) incision depending on graft type and size between Jul and Dec in 2019 at a single center. Donor demographics, preoperative data, and postoperative outcomes were analyzed.
Results: The mean age of the donors was 32.8 ± 10.3 years old, and 32 (50.8%) donors were male. The mean operation time was 400.5 ± 69.5 minutes and the mean hospital stay was 9.4 ± 3.7 days. The graft types comprised 52 (82.5%) of the modified right lobe, 6 (9.5%) of the modified extended right lobe, and 5 (7.9%) of the extended left lobe. The portal vein types were I, II, and III in 59 (93.7%), 1 (1.6%), and 3 (4.8%), respectively. The bile duct types were A, B, C1, and C2 in 46 (73.0%), 8 (12.7%), 3 (4.8%), and 6 (9.5%). There were two cases of major complications, one (1.6%) case of bile leakage and one (1.6%) case of abdominal wall bleeding after donor hepatectomy.
Conclusions: LDH using minimal incision was a safe and feasible option showing an acceptable incidence of complications despite anatomical variations.
PT02-32 The Impact of Porto-Arterial Flow Ratio on Survival for Patients Underwent Living Donor Liver Transplantation
Deniz Balci, Turkey

E.O. Kirimker1, U. Goktug1, M. Uysal1, G. Cinar2, S. Karadag Erkoc3, E. Ustuner4, M. Bingol Kologlu5, K. Karayalcin1, D. Balci1
1Surgery, Ankara University, Turkey, 2Infectious Diseases, Ankara University, Turkey, 3Anaesthesiology and Reanimation, Ankara University, Turkey, 4Radiology, Ankara University, Turkey, 5Pediatric Surgery, Ankara University, Turkey

Introduction: Optimal portal and hepatic arterial flow to the liver graft is essential for the succesful liver transplantation. In here analysis of hepatic inflow measurements and and outcomes are presented in the setting of adult living donor liver transplantation.
Method: Liver transplantations which were performed between October 2016 December 2019 at Ankara University Hospitals were included the study. Pediatric and cadaveric cases were excluded from the study. Intraoperative arterial and portal flow was measured with a doppler flowmeter device at the end of the operation and repeated if splenic artery was ligated.
Results: A total of 103 patients were included. Mean BMI 26.61 kg/m2(16.0-36.1). Sixty-six (64.1%) patients were male. Right lobe grafts were utilized for 89 (86.4%) patients. Mean GRWR was 1.07 (0.36-1.81). Mean arterial flow was 107.2 ml/min and mean portal flow was 1462 ml/min. Splenic artery was ligated in 32 cases for inflow modulation. When portal flow over hepatic arterial flow ratio (PAFR) higher than 20 representing high portal flow and low arterial flow was chosen as cut-off value and patients compared in terms of survival with Kaplan-Meier curves and Log-Rank Test, high PAFR was found to be associated with survival (p=o.043). GRWR of patients were similar between groups (p=0.833)
Conclusion: In this study final PAFR is related survival benefit. Maneuvers for graft inflow modification to decrease PAFR below 20 might be useful to improve outcome. Coefficients which can be calculated with larger cohorts may be useful for prediction of outcomes
[Kaplan Meier curves of patient groups porto arterial flow ratio higher than 20 vs below 20]
PT02-35 Compromised AMPK-PGC1α Axis Exacerbated Steatotic Graft Injury by Dysregulating Mitochondrial Homeostasis in LDLT
Jiang Liu, China

J. Liu1, K. Man2, C.-M. Lo2, J. Dong1
1Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, China, 2Department of Surgery & HKU-Shenzhen Hospital, The University of Hong Kong, China

Introduction: The utilization of steatotic graft expands the donor pool for living donor liver transplantation (LDLT). However, it remains controversial due to its high morbidity and mortality. Thus determining the safety degree of graft steatosis and elucidating the mechanism of steatotic graft injury is crucial to develop therapeutic strategies targeting at graft injury and to further expand the donor pool.
Methods: Five hundred and thirty patients receiving LDLT were prospectively included for risk factor analysis and outcome comparison. Rat orthotopic liver transplantation, in vitro functional experiments and mouse hepatic ischemia/reperfusion models were established to explore the mechanisms of steatotic graft injury.
Results: We identified that graft with >10% steatosis was an independent risk factor for long-term graft loss after LDLT (HR=2.652, p=0.001), and was associated with shorter cancer recurrence-free survival and acute phase liver injury in LDLT patients. Steatotic graft displayed distinct mitochondrial dysfunction, including membrane, calcium and energy homeostasis failure. Specifically, the mitochondrial biogenesis was remarkably down-regulated in steatotic graft. Inhibition of AMPK-PGC1α axis impaired mitochondrial biogenesis and was lethal to fatty hepatocyte in vitro, whereas reactivation of AMPK promoted PGC1α-mediated mitochondrial biogenesis and attenuated liver injury via restoring mitochondrial function in animal model.
Conclusion: We provided a new mechanism of compromised AMPK-PGC1α axis exacerbated steatotic graft injury in LDLT by driving mitochondrial homeostasis failure through impairment of biogenesis.