Simultaneous pancreas-kidney transplantation: lessons learned from the initial experience of a single center in Korea

PURPOSE: The purpose of this study is to report the results of simultaneous pancreas-kidney (SPK) transplantations and describe the lessons learned from the early experiences of a single center. METHODS: Between January 2002 and June 2013, a total of 8 patients underwent SPK transplantation. Clinical and radiologic data were reviewed retrospectively. RESULTS: Seven patients were diagnosed with type I diabetes mellitus and one patient became insulin-dependent after undergoing a total pancreatectomy because of trauma. Pancreas exocrine drainage was performed by enteric drainage in 4 patients and bladder drainage in 4 patients. Three patients required conversion from initial bladder drainage to enteric drainage due to urinary symptoms and duodenal leakage. Four patients required a relaparotomy due to hemorrhage, ureteral stricture, duodenal leakage, and venous thrombosis. There was no kidney graft loss, and 2 patients had pancreas graft loss because of venous thrombosis and new onset of type II diabetes mellitus. With a median follow-up of 76 months (range, 2-147 months), the death-censored graft survival rates for the pancreas were 85.7% at 1, 3, and 5 years and 42.9% at 10 years. The patient survival rate was 87.5% at 1, 3, 5, and 10 years. CONCLUSION: The long-term grafts and patient survival in the current series are comparable to previous studies. A successful pancreas transplant program can be established in a single small-volume institute. A meticulous surgical technique and early anticoagulation therapy are required for further improvement in the outcomes.

Effectiveness of Early Enteral Feeding in Major Burn Patient

PURPOSE: Early enteral feeding is recommended in cases of critical illness. However, it is unclear whether this recommendation is of most benefit to extremely ill patients. From our experiences, our authors believed that early enteral nutrition can lead to better prognosis of ICU patients. We aim to clarify the efficacy of early enteral feeding. METHODS: Eighty six critically ill patients were enrolled and grouped as "Early enteral feeding (EF)" and "Delayed enteral feeding (DF)" for this cross-sectional, prospective randomized observational study. To reduce the selection bias, we compare our groups to 20~39% (group A) TBSA (total body surface area, and 40~59% (group B) TBSA burned. BMI (body mass index), length of ICU stay, length of hospital stay, hospital mortality, serum prealbumin, serum transfferin and lymphocyte count data were collected over 28 days. RESULTS: There were no statistical differences in measured outcomes between early and late feeding groups. In serologic test; prealbumin, transferrin and lymphocyte, there is also no statistical difference except 2nd, 4th week of lymphocyte. EF group has higher lymphocyte than DF group. In the group A, however, prealbumin and transferrin was high in EF group during the whole 4 weeks of study. Comparing the ICU stay and hospital mortality, there was also no statistical significance. CONCLUSION: In this study, there is no significant association between hospital outcomes and timing of enteral feeding initiation. More active trials and many-sided studies will be needed to maximize the effect of early enteral nutritional support as a method to improve treatment for major burned patients.

Laparoscopic Resection of an Asymptomatic Intra-Abdominal Lymphangioma / 대한내시경복강경외과학회지

An intra-abdominal cystic lymphangioma is a benign neoplasm that rarely occurs within the abdominal cavity. Intra-abdominal cystic lymphangioma is treated by a resection performed through a radical procedure. We report a case of a 37-year-old woman who had an asymptomatic mesenteric cyst that was discovered incidentally during a routine physical check-up. Treatment was completed without complications using a laparoscope.

Analysis of the Potential Deceased Donors in the Neurosurgical Intensive Care Units of Korea / 대한이식학회지

BACKGROUND: The shortage of donor organs is the main problem that needs to be solved in Korea as well as in other countries. To expand the donor pool, we retrospectively reviewed the brain-dead patients who expired without organ donation in the neurosurgical intensive care units (NICU) and evaluated the potential deceased donors (PDDs). METHODS: Between January 2008 and December 2008, PDDs who expired without organ donation in the NICU were recruited from 52 secondary or tertiary referral hospitals in Korea. The data of a total 2,288 PDD cases were collected from the questionnaire. Of these, 1,980 cases were eligible for analysis. RESULTS: There were 1,166 males (58.9%) and 793 females (40.1%) with a mean age of 57.6+/-18.0 years (21.2% in the 5th decade; 21.0% in the 6th decade). The most common cause of death of PDDs was cerebrovascular accident (n=1,034; 52.2%). Glasgow Coma scale was 3 in 23.1% and 4 in 12.1% of the PDDs. Craniotomy was performed in 996 patients (50.3%). Sepsis developed in 276 patients (14.0%) among the total PPDs. Diagnostic procedure for assessment of brain death was performed in 194 patients (9.8%). The seroprevalence of HBsAg and HCVAb was 1.7% and 0.6%, respectively. The mean AST/ALT level on admission and after brain death were 80.9+/-344.9/49.0+/-162.19 and 308.6+/-1,485.2/142.5+/-596.27 IU/L, respectively. Uriney protein level was normal in 1,221 patients (61.7%) after brain death. Of the 1980 PDDs, 19 patients (1%) donated their organs for transplantation. CONCLUSION: Only a small percentage (1%) of PDDs in the NICU donated their organs in Korea. We suggest that continuous and active donor action is needed to increase organ donation from the potential deceased donors.

Surgical Treatment of Acute Arterial Occlusion after Applying the Vascular Closure Device for Hemostasis of Femoral Arteriotomy in Vascular Intervention

Vascular intervention via the femoral artery can cause vascular access complications and complications from closure of the arteriotomic incision site such as bleeding, thrombotic complications and vascular trauma. These types of complications occur in about 2% to 10% of the cases. After removal of the catheter, hemostasis is traditionally achieved by manual compression as a standard method. Many vascular closure devices have been developed in an attempt to improve the patient's comfort and to decrease the time to ambulation. Yet the safety and effectiveness of these vascular closure devices as compared to that of manual compression remains unclear. Herein we report on a case of femoral arterial occlusion due to vascular closure devices and the operative management.

A Case of Cyclosporine-Induced Type I Renal Tubular Acidosis after Kidney Transplantation / 대한신장학회지

Cyclosporine is an immunosuppressive agent that plays an important therapeutic role for organ transplantation. However, complications due to type 1 renal tubular acidosis, albeit rare, have been reported. We experienced a case of severe metabolic acidosis associated with cyclosporine administration after renal transplantation. A 54-year old man was hospitalized for seizure, confusion and weakness. He demonstrated severe metabolic acidosis and hypokalemia. Continuous renal replacement therapy was started and sodium bicarbonate was administered to correct the acidosis and the dosage of cyclosporine was reduced. Thereafter, the cyclosporine level in whole blood decreased gradually, and the metabolic acidosis improved.

Laparoscopic vs Transumbilical Single-Port Laparoscopic Appendectomy; Results of Prospective Randomized Trial

PURPOSE: Conventional three-port laparoscopic appendectomy (LA) is more commonly performed than transumbilical single port laparoscopic appendectomy (TUSPLA). In this report, we performed a prospective randomized study comparing the outcomes of LA and TUSPLA. METHODS: Between April 14, 2009 and June 10, 2009, 40 patients who required laparoscopic appendectomies were randomly selected to receive either a TUSPLA or a LA. None of these patients had perforation or abscess. Twenty of the patients received a LA and the other 20 received a TUSPLA. The clinical outcomes and visual analog pain scores (VAS) were compared between the groups. RESULTS: The TUSPLA procedures were performed successfully in every indicated patient. Clinical outcomes were similar in both study groups. The TUSPLA group showed a significantly higher VAS score 24 hours postoperatively than the LA group. CONCLUSION: Compared with LA, TUSPLA was technically feasible and safe in patients with non-complicated appendicitis. However, the patients in the TUSPLA group reported more postoperative pain than those in the LA group.

Expression of E-cadherin, Heat Shock Protein 47, Transforming Growth Factor beta1 and C4d in Chronic Allograft Nephropathy / 대한이식학회지

BACKGROUND: Chronic allograft nephropathy (CAN), which causes graft failure, is related to tubular atrophy and interstitial fibrosis. E-cadherin is a well-known epithelial marker and heat shock protein (HSP)-47 is a collagen-specific molecular chaperone that regulates collagen synthesis. Transforming growth factor (TGF)-beta1, a profibrotic cytokine, downregulates E-cadherin and induces expression of mesenchymal markers in an in vitro model. C4d expression is considered a poor prognostic marker for graft survival. This study evaluated the relationship between the expression of E-cadherin, HSP47, TGF-beta1, and C4d with the prognosis for CAN. METHODS: Between March 1991 and August 2007, we performed renal allograft biopsies on 42 recipients with deteriorating renal function. CAN was diagnosed according to the chronic allograft damage index (Banff classification). Renal allograft biopsies were examined for the expression of E-cadherin, HSP47, TGF-beta1, or C4d by immunohistochemistry. The HSP47, TGF-beta1, and E-cadherin staining was scored semiquantitatively by analyzing ten different fields of cortical interstitium and tubules. Biopsies with endothelial C4d staining in peri-tubular capillaries (> or =25%) were designated as C4d-positive. RESULTS: Of 42 recipients, 17 (40.5%) were in the graft survival group (GS) and 25 (59.5%) were in the graft failure group (GF). E-cadherin expression in tubular cells of the GS was much higher than that of the GF (94.1% vs 52%, P=0.04). HSP47 expression in tubular cells and interstitium in the GF was much higher than that in the GS (84% vs 35.3%, P=0.001). TGF-beta1 expression in tubular cells and interstitium in the GF was much higher than that in the GS (72% vs 23.5%, P=0.02). CONCLUSIONS: E-cadherin, HSP47, and TGF-beta1 expression was strongly correlated with the CAN prognosis.

The Minimal Invasive Approach for Early Gastric Cancer with Abdominal Aortic Aneurysm

Around two-thirds of all abdominal aortic aneurysms (AAA) are incidentally discovered. Open surgical repair of these aneurysms is considered the standard, traditional method of treatment. This report details the minimal invasive approach for a patient who presented with early gastric cancer and an AAA, and the patient underwent endovascular repair of the aneurysm prior to laparoscopic assisted distal gastrectomy. Esophagogastroduodenoscopy identified a malignant ulcer in the antrum and preoperative abdominal computer-tomography incidentally revealed a large AAA. The abdominal aortic aneurysm was the infra-renal type and the estimated size was 65 mm. Compared to open surgical intervention, the treatment of abdominal aortic aneurysm via endovascular aneurysm repair (EVAR) shortens the period of recovery. Also, intra-abdominal adhesion is avoided so that minimal invasive surgical intervention through the laparoscopic approach is possible for treating malignancy. EVAR is the recommended treatment for asymptomatic abdominal aortic aneurysm when this is associated with intra-abdominal malignancy.

A Case of Kaposi's Sarcoma Improved by Sirolimus Treatment in the Kidney Transplant Recipient / 대한신장학회지

The incidence of Kaposi's sarcoma (KS) increases in kidney transplant recipients who had the immunosuppressive therapy. The usual treatment of KS is to reduce the dosage of immunosuppressive agents, with chemotherapy and/or radiotherapy. Several studies have recently demonstrated that the conversion to proliferation signal inhibitors (PSIs) from calcineurin inhibitors (CNI) leads to the remission of some post-transplant tumors such as KS. PSIs were well tolerated with stable renal function and no episode of acute rejection was reported. On the basis of these findings, we report a case of Kaposi's sarcoma in the kidney transplant patient, who had multiple lymphadenopathy and hepatic involvement without skin lesions. This patient responded well to the change of the immunosuppressive treatment from cyclosporine to sirolimus, one of PSIs.

Decision Factors on Mycophenolic Acid Dose after Renal Transplantation / 대한이식학회지

BACKGROUND: Triple immunosuppressant therapy including anti-metabolites is the representative immunosuppressive therapy after renal transplantation. This study is to evaluate the factors that influence Mycophenolate sodium (MPS, Myfortic, Novartis, Basel, Switzerland) dosage patterns in renal transplantation patients who take MPS as an inosine monophosphate dehydrogenase (IMPDH) among antimetabolites. METHODS: From May 2007 to April 2008, 16 clinical departments of 14 transplantation centers in Korea retrospectively performed a survey on 650 renal transplantation recipients taking MPS. This survey collected personal information, clinical factors related to transplantation and immunosuppressive therapy. RESULTS: The mean age of the patients was 43.0+/-12.0 (7~75) and the study included 364 males (56.0%) and 286 females (44.0%). The average follow up period after renal transplantation was 49.5+/-53.4 (1~307) months. There were 366 (56.3%) living related cases, 145 (22.3%) living non-related cases and 139 (21.4%) deceased donor cases. Cyclosporine was the most common calcineurin inhibitor (CNI) used in combination therapy with MPS (476 cases, 73.2%) followed by tacrolimus (169 cases, 26.0%). The mean daily dose of MPS was 909.7+/-336.3 (180~1,620)mg and the mean daily dose per kg was 15.3+/-5.9 (2.65~32.73)mg/kg. The daily dose showed significant positive correlation with patient body weight but the daily dose per kg showed negative correlation. The daily dose of MPS was significantly higher in the combination therapy with cyclosporine than that with tacrolimus. The daily dose and the dose per kg decreased with increment of recipient age and post-transplant period. CONCLUSIONS: Our study concluded that MPS dosages correlated with the combined type of CNI, post-transplant period and age.

Kaposi's Sarcoma on Mediastinum after Renal Retransplantation

Kaposi's sarcoma occurs in higher rates in the setting of immunosuppression, especially in patients with acquired immunodeficiency syndrome (AIDS), immunosuppressive therapy or posttransplantation, commonly involving the skin, visceral, oral cavity or respiratory tract. Of the de novo malignancies in transplantation patients, the incidence of Kaposi's sarcoma is increasing steadily. We report a case of a 37-year-old male patient who was diagnosed with Kaposi's sarcoma 16 years after his first renal transplantation and 5 months after his second transplantation. He presented with lymphoproliferative lesions in the mediastinum and supraclavicular area without showing any typical cutaneous lesions. Diagnosis was confirmed by gun biopsy of the enlarged axillary lymph nodes. Tacrolimus, the initial immunosuppressive drug, was tapered while sirolimus therapy and chemotherapy with vincristine was initiated. The enlarged lymph nodes decreased in size and the patient has been treated with vincristin and conversion of tacrolimus to sirolimus.

Feasibility of Laparoscopic Appendectomy for Complicated Appendicitis / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic appendectomy (LA) is now widely practiced in most medical centers, yet there is no consensus regarding the indications and advantages of LA over the conventional technique. Various reports have demonstrated conflicting results about the merit of LA. Especially, complicated appendicitis was initially considered as a contraindication for LA. However, with the improvements of laparoscopic instruments and the technical proficiency, the choice of the operative approach mostly depends on the surgeon's experience or the patient's preference. Here we compared the outcome of LA versus open appendectomy (OA) overall and specifically in the patients with complicated appendicitis. METHODS: From January 2007 to December 2007, the records of 495 patients with the diagnosis of appendicitis were retrieved from the computer database for analysis. All the patients had given informed consent for LA or the OA technique and the patients chose the operative method. The two groups were compared with respect to the patients' demographic data, the clinical outcomes, the cost and the type of pathology RESULTS: During the study period, 195 patients (39.4%) underwent LA and 300 patients (60.6%) underwent OA. There were 53 cases (27.1%) of complicated appendicitis and 105 cases each (35%) in the LA and OA groups, respectively. The patients of the LA group revealed a significant female prevalence, a shorter hospital stay, less use of analgesics, a lower complication rate and a higher cost (p<0.005), and also a comparable operation time to the OA group. As for the complicated appendicitis, there was benefit for only the hospital stay. CONCLUSION: Usually LA has more advantage than OA except cost. Even in complicated appendicitis, LA is feasible without increase of complication.

Comparison of New Onset Diabetes according to the Time of Onset in Kidney Transplant Recipients / 대한이식학회지

BACKGROUND: New onset diabetes is a common complication after kidney transplantation. However, the clinical course of post-transplant diabetes mellitus (PTDM) remains unclear. The aim of the present study is to analyze the natural courses and risk factors of PTDM according to the time of onset. METHODS: A total of 216 consecutive kidney transplant recipients were enrolled and patient medical records were investigated retrospectively. PTDM was defined as glucose > or =126mg without previous diabetic history. Patients were classified according to the onset (12 months): early PTDM (E-PTDM) and late PTDM (L-PTDM). RESULTS: PTDM was observed in 34 (17.4%) patients. The number of E-PTDM and L-PTDM patients was 17 and 17. Compared with normoglycemic patients, the PTDM group was older and showed higher pre-transplant HbA1c level. The use of tacrolimus was associated with the development of E-PTDM (OR=4.87, 1.71~13.8 in 95% CI) but not L-PTDM (OR=0.34, 0.04~2.70 in 95% CI) CONCLUSIONS: The development of E-PTDM and L-PTDM may have different risk factors. It will be important to choose different therapeutic strategy according to the onset of PTDM.

Laparoscopic Cholecystectomy in Patients with a Left-sided Gallbladder

Laparoscopic cholecystectomy has been widely performed as the gold standard for patients suffering with symptomatic gallstone disease. However, conversion to open cholecystectomy is a dilemma when the surgeon encounters a variant biliary anomaly. A gallbladder lying to the left of the round ligament represents a rare congenital anomaly, which is termed as a left-sided gallbladder. The true left-sided gallbladder, situated on the inferior aspect of the left lobe of the liver, is extremely rare and this represents a truly ectopic gallbladder that may developmentally arise as a second gallbladder from the left hepatic duct. This is accompanied by the disappearance of the normal gallbladder on the right side. We report here on 2 cases of left-sided gallbladder that were successfully treated with laparoscopic cholecystectomy at Hallym Medical Center. In both cases, the true left-sided gallbladders were identified intraoperatively. The round ligament was indeed located in its normal position, and the gallbladder was located to the left of the round ligament, which is a type of malposition known as sinistroposition. The operation was carried out in the usual manner with the trocars placed their usual location. Although operations can be carried out with using the standard port sites, a better arrangement for laparoscopic cholecystectomy consists of more medial positioning of the gallbladder-retracting port and placement of the right hand operating port to the left side of the round ligament.

The Effect of Compliance, Family Support and Graft Function on Quality of Life in Kidney Transplant Recipients / 대한이식학회지

BACKGROUND: Previous studies have shown that kidney transplant recipients' quality of life depend on compliance of treatment, family support, socioeconomic status. The purpose of this study was to determine whether estimated glomerular filtration rate (GFR) by Modification of Diet in Renal Disease (MDRD) study as a index of graft function influence recipients' quality of life including above mentioned factors. METHODS: One hundred and ten patients who visited out-patient department at least 3 months after kidney transplantation were included in this study. A structured questionnaire was used to collect data. This tool included; quality of life, compliance and family support scale as well as medical record review. The analysing of data was performed with SPSS version 11.5 (SPSS Inc. Chicago, IL, USA). RESULTS: The mean score of the recipients' quality of life (3.59/5), compliance (3.81/5), the support of family (4.02/5) and GFR (63 ml/min/1.73 m2) were revealed respectively. The quality of life was correlated with compliance (r=.260, P<.001) and family support (r=.377, P<.001) statistically. and compliance and family support also revealed correlation (r=.452, P<.001). Family support was the most explainable factor for the quality of life (R2=.142). however, the quality of life was not correlated with recipients' GFR (r=.013 P=0.819). CONCLUSIONS: Results of this study showed that kidney transplant recipients had a moderate quality of life. These findings suggest that emotional aspect like family support is as important as clinical factors such as GFR or compliance for recipients' quality of life. To optimize post-transplant quality of life, implication for interventional programming should be focused on family support.

A Case of Endobronchial Aspergillosis in a Renal Transplant Patient / 대한신장학회지

In immunocompromised renal transplant patients, aspergillosis can be a life-threatening opportunistic infection. Aspergillus is a ubiquitous organism in our environment, so pulmonary aspergillosis usually results from the ingrowths of the colonized Aspergillus in bronchial trees, pulmonary cysts or cavities. We have experienced a case of endobronchial aspergillosis developed in a renal transplant patient with neutropenia. Bronchoscopic biopsy revealed a necrotizing Aspergillus bronchitis in the orifice of the lateral segmental bronchus of left upper lobe. The patient received total 2,760 mg intravenous liposomal amphotericin B. There was no endobronchial lesion on follow up bronchoscopy and biopsy was also negative. This case serves as a reminder to clinicians that Aspergillus should be kept in mind as a possible infectious organism in renal transplant patients.

The Clinical Significance of the Hypoxia Inducible Factor-1 alpha and C4d in Implantation Renal Biopsies and Post-transplant Biopsies / 대한이식학회지

PURPOSE: Hypoxia inducible factor-1 alpha (HIF-1 alpha) is induced in response to ischemic states and in turn activates transcription of several growth factors implicated in cell survival. These growth factors have been recognized as role players in the development of chronic allograft nephropathy (CAN). C4d depositions in the peritubular capillaries of renal allografts have been reported to be sensitive markers of acute humoral rejection. The purpose of this study was to determine the effects of HIF-1 alpha expression and C4d deposition in implantation biopsies of renal allografts. METHODS: Implantation biopsies and 22 rejection proven biopsies of 54 renal transplantation recipients (Male:Female=31:23) in Kangdong Sacred Heart Hospital from December 1996 to July 1999 were done. Immunohistochemical studies were performed using mouse monoclonal antibody (1:1000, Novus Biological Inc., Littleton, CO, USA) as the primary antibody and CSA (Catalyzed Signal Amplification System, Dako, Denmark) as the secondary antibody for HIF-1 alpha. Rabbit polyclonal antibody (1:200 Biogenesis, UK) and DAB kit (Dako) were used for C4d detection. Expression of HIF-1 alpha was defined as positive nuclei staining under 10 HPF (high power field) and C4d deposition was defined as 1+ when the pericapillary deposition was under 50% and 2+ when over 50% and 0 when there were no traces of depo sition. RESULTS: HIF-1 alpha was demonstrated in 19 cases (35%) of the 54 implantation biopsy cases. The expression of HIF-1 alpha was statistically higher in the deceased donor group compared to the living donor group. The HIF-1 alpha positive group had a longer mean cold ischemic time than the HIF-1 alpha negative group but was not statistically significant. The age of the donor and HIF-1 alpha expression showed no correlation. Expression of HIF-1 alpha of the implantation biopsies also showed no difference in the rejection group (n=22) compared to the non-rejection group (n=32). There was no significant difference of HIF-1 alpha expression in the graft loss group (n=7) and the graft functioning group (n=47). C4d deposition was detected in one implantation allograft biopsy (1.9%). The C4d positive patient developed acute accelerated rejection on the fourth postoperative day. HIF-1 alpha and C4d were demonstrated in 22 (100%) and 11 (50%) of the 22 rejection biopsies, respectively. In patients who showed rejection, HIF-1 alpha expression was significantly higher in the rejection biopsies compared to the implantation biopsy group. HIF-1 alpha expression of the patients who showed rejection within one month and those with rejection later than three months after engraftment showed no significant difference. CONCLUSION: Expression of HIF-1 alpha in implantation biopsies showed significant correlation with deceased kidney donors. The relation with cold ischemic time was not statistically proven but the HIF-1 alpha positive group showed a tendency of longer cold ischemic time. Biopsies from the renal allografts with rejection showed significantly higher expression of HIF-1 alpha compared to the implantation biopsies. The deposition rate of C4d was extremely low in implantation biopsies that we could not prove any relevance with acute rejection.

Simultaneous Pancreas-kidney Transplantation from Pediatric Donor: A Case Report / 대한이식학회지

Simultaneous pancreas-kidney (SPK) transplantation is a well-established treatment for patients with insulin-dependent DM complicated by ESRD. The current shortage of cadaver donors and the increasing number of diabetic patients on the transplant waiting list has prompted the use of cadaveric organ from pediatric donors. But the lower age limit of the pancreatic donors has not yet been established. We report the successful result using a 10 years old donor for a 36-year-old SPK transplant recipient.

Liver Transplantation for a Cirrhotic Patient with Situs Inversus

Situs inversus refers to a mirror image of the viscera, while situs solitus is defined as the normal anatomical situation. Several cases of successful liver transplantation for situs inversus recipients have been reported, and modifications of the standard surgical techniques were used. We report here on a case of cadaveric liver transplantation in an end-stage liver disease patient with situs inversus. The donor liver was rotated clockwise 90 degrees to the left with the right lobe lying in the left upper quadrant and the left lobe pointing down into the left iliac fossa. The donor's suprahepatic vena cava was oversewn and the infrahepatic vena cava anastomosed end to side to the recipient's inferior vena cava. The postoperative course was good until the postoperative 26th day, when rupture of a hepatic artery pseudoaneurysm occurred. An emergency laparotomy was done and the hepatic artery was ligated. Despite the hepatic artery ligation, the liver function recovered quite well. But sudden intracranial hemorrhage developed on the postoperative 28th day and sadly, the patient expired on the postoperative 30th day. Complete preoperative evaluation of the recipient is essential for the operative planning, and careful donor selection should be attempted to obtain a smaller graft to allow maximum flexibility for placing the donor liver. The use of a reduced-sized graft should be considered in the case for which a smaller graft is not available. In conclusion, adult situs inversus is no longer a contraindication for a liver transplant, although technical difficulties do exist for this procedure.