Fate of Surgical Patients with Small Nonfunctioning Pancreatic Neuroendocrine Tumors: An International Study Using Multi-Institutional Registries.

Several treatment guidelines for sporadic, nonmetastatic nonfunctioning neuroendocrine tumors of the pancreas (NF-pNETs) have recommended resection, however, tumors ≤ 2 cm do not necessarily need surgery. This study aims to establish a surgical treatment plan for NF-pNETs ≤ 2 cm. From 2000 to 2017, 483 patients who underwent resection for NF-pNETs ≤ 2 cm in 18 institutions from Korea and China were enrolled and their medical records were reviewed. The median age was 56 (range 16-80) years. The 10-year overall survival rate (10Y-OS) and recurrence-free survival rate (10Y-RFS) were 89.8 and 93.1%, respectively. In multivariable analysis, tumor size (>1.5 cm; HR 4.28, 95% CI 1.80-10.18, p = 0.001) and nodal metastasis (HR 3.32, 95% CI 1.29-8.50, p = 0.013) were independent adverse prognostic factors for OS. Perineural invasion (HR 4.36, 95% CI 1.48-12.87, p = 0.008) and high Ki-67 index (≥3%; HR 9.06, 95% CI 3.01-27.30, p < 0.001) were independent prognostic factors for poor RFS. NF-pNETs ≤ 2 cm showed unfavorable prognosis after resection when the tumor was larger than 1.5 cm, Ki-67 index ≥ 3%, or nodal metastasis was present. NF-pNET patients with tumors ≤ 1.5 cm can be observed if the preoperative Ki-67 index is under 3%, and if nodal metastasis is not suspected in preoperative radiologic studies. These findings support the clinical use to make decisions about small NF-pNETs.

Usefulness of artificial intelligence for predicting recurrence following surgery for pancreatic cancer: Retrospective cohort study.

BACKGROUND: or Purpose: Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of mortality in the world with the overall 5-year survival rate of 6%. The survival of patients with PDAC is closely related to recurrence and therefore it is necessary to identify the risk factors for recurrence. This study uses artificial intelligence approaches and multi-center registry data to analyze the recurrence of pancreatic cancer after surgery and its major determinants. METHODS: Data came from 4846 patients enrolled in a multi-center registry system, the Korea Tumor Registry System (KOTUS). The random forest and the Cox proportional-hazards model (the Cox model) were applied and compared for the prediction of disease-free survival. Variable importance, the contribution of a variable for the performance of the model, was used for identifying major predictors of disease-free survival after surgery. The C-Index was introduced as a criterion for validating the models trained. RESULTS: Based on variable importance from the random forest, major predictors of disease-free survival after surgery were tumor size (0.00310), tumor grade (0.00211), TNM stage (0.00211), T stage (0.00146) and lymphovascular invasion (0.00125). The coefficients of these variables were statistically significant in the Cox model (p < 0.05). The C-Index averages of the random forest and the Cox model were 0.6805 and 0.7738, respectively. CONCLUSIONS: This is the first artificial-intelligence study with multi-center registry data to predict disease-free survival after the surgery of pancreatic cancer. The findings of this methodological study demonstrate that artificial intelligence can provide a valuable decision-support system for treating patients undergoing surgery for pancreatic cancer. However, at present, further studies are needed to demonstrate the actual benefit of applying machine learning algorithms in clinical practice.

Analysis of post-operative complication in single-port laparoscopic cholecystectomy: A retrospective analysis in 817 cases from a surgeon.

BACKGROUND: Single-port laparoscopic cholecystectomy (SPLC) is a new advanced technique in laparoscopic surgery which has many benefits according to previous reports. The purpose of this study was to present personal experiences with SPLC in >800 cases performed by a surgeon to evaluate the safety and feasibility of this procedure. MATERIALS AND METHODS: A retrospective review of 817 cases of SPLC was conducted. All patients had received elective SPLC by a surgeon in our centre during March 2009-August 2015. Our review suggests patients' character, peri-operative data and post-operative outcome. RESULTS: Three hundred and ninety-eight men (48.7%) and 419 women (51.3%) with an average age of 48.3 years had received SPLC. Their mean body mass index (BMI) was 23.75 kg/m2. The mean operating time took 46.9 min (19-130). Seventy-nine cases (9.7%) needed additional port during operation. BMI, age and previous abdominal surgical history did not affect conversion to multiport surgery. Bile spillage during operation occurred in 73 cases (8.9%). There were 4 cases of open conversion because of bleeding (2 cases, 0.2%) and common bile duct (CBD) injury (2 cases, 0.2%). Mean duration of hospital stay was 2.36 days. We have experienced 38 cases (4.7%) of post-operative complication: 8 cases (1.0%) of major one and 30 cases (3.7%) of minor one. Major complication occurred in 3 cases (0.4%) of retained CBD stone, 3 cases (0.4%) of cystic duct leakage needed endoscopic retrograde cholangiopancreatography and 2 cases (0.2%) of CBD injury needed reoperation. Most minor complications were wound infections that have healed after conservative treatment. There were no post-operative mortalities. CONCLUSION: SPLC is a safe and practicable technique. With surgical experience, criteria and area of SPLC can be broadened. SPLC is occupying a greater domain of a laparoscopic cholecystectomy.

Initial Outcomes of Pure Laparoscopic Living Donor Right Hepatectomy in an Experienced Adult Living Donor Liver Transplant Center.

BACKGROUND: Only a limited number of centers have performed laparoscopic living donor hepatectomy to date. In particular, laparoscopic right hepatectomy is rarely performed because the procedure can only be performed by surgeons with significant experience in both laparoscopic liver surgery and liver transplantation with living donor liver grafts. METHODS: Between November 2014 and February 2015, in a pure laparoscopic approach program for living right lobe donors at Asan Medical Center, 92 living donors underwent right hepatectomy for adult living donor liver transplantation. Among these, 3 pure laparoscopic living donor right hepatectomies were performed in 3 young female donors. RESULTS: The intraoperative and postoperative courses for all 3 donors and recipients were uneventful without any complications. Laparoscopic living donor hepatectomy has definite advantages over conventional open surgery, including decreased wound morbidity and faster recovery. CONCLUSIONS: According to the data of the present report, pure laparoscopic living donor right hepatectomy in properly selected living donors (only 4% of potential donors in this cohort) appears to be a safe and feasible procedure in adult living donor liver transplantation.

Pure Laparoscopic Versus Open Right Hepatectomy for Hepatocellular Carcinoma in Patients With Cirrhosis: A Propensity Score Matched Analysis.

OBJECTIVE: We aimed to describe our experience with pure laparoscopic right hepatectomy (LRH) and to compare its outcomes with those of open right hepatectomy (ORH) in hepatocellular carcinoma (HCC) patients with liver cirrhosis. BACKGROUND: Laparoscopic liver resection has been reported as a safe and effective approach for the management of liver cancer; however, its outcomes have not been evaluated in a large cohort of HCC patients with liver cirrhosis. METHODS: We retrospectively reviewed the medical records of 152 patients who underwent pure LRH (n = 37) or ORH (n = 115) between June 2008 and July 2015 at the Asan Medical Center in Seoul, Korea. We performed 1:1 propensity score matching between the LRH and ORH groups. Subsequently, 33 patients were included in each group. RESULTS: There was no statistically significant difference between the LRH and ORH groups regarding the rate of complications (P = 0.053). However, the mean comprehensive complication index, which accounts for the severity of complications, was significantly lower in the LRH group (0.63 vs 4.42; P = 0.025). There were no significant differences between the LRH and ORH groups regarding 2-year disease-free survival rate or 2-year overall survival rate (P = 0.645 and P = 0.090, respectively). CONCLUSIONS: Even in patients with cirrhosis, pure LRH is not less safe than the traditional open approach. The oncological outcomes of HCC were also comparable between the two groups. In selected patients, pure LRH for HCC appears to represent a viable alternative to ORH.

Surgical outcomes following laparoscopic major hepatectomy for various liver diseases.

The aim of the study was to report surgical outcomes (efficacy and safety) of laparoscopic major hepatectomy for various liver diseases.Although the number of laparoscopic liver resections has increased, expansion of laparoscopic major hepatic resection remains limited, mainly owing to the technical difficulties for the procedure as compared to open surgery. We describe our experiences with laparoscopic major hepatectomy for various liver diseases.We retrospectively reviewed the medical records of 192 patients who underwent laparoscopic major hepatectomy between October 2007 and March 2015 at Asan Medical Center, Korea.The mean age of the patients was 54 ±â€Š11.6 years, and their mean body mass index was 23.5 kg/m. The most common preoperative diagnosis was hepatocellular carcinoma (n = 82, 42.7%), followed by intrahepatic duct stones (n = 51, 26.6%). We performed 108 left hepatectomies, 55 right hepatectomies, 18 right posterior sectionectomies, 6 right anterior sectionectomies, 2 central bisectionectomies, and 3 donor right hepatectomies. The conversion rate was 1.6% (3 cases) due to bleeding, bile leakage, and uncontrolled hypercapnea during the operation. The mean operation time was 272 ±â€Š80.2 minutes, and the mean estimated blood loss was 300.4 ±â€Š252.2 mL. The mean postoperative hospital stay was 9.8 days. All resection margins were tumor-free in cases of malignant tumors. The morbidity rate was 3.1% (n = 6), including for case of biliary stricture. There were no deaths.Laparoscopic major hepatectomy, including donor hepatectomy, is a safe and feasible option for various liver diseases when careful selection criteria are used by a surgeon experienced with the relevant surgical techniques.

Effect of reoperation on long-term outcome of pT1b/T2 gallbladder carcinoma after initial laparoscopic cholecystectomy.

BACKGROUND: A small proportion of gallbladder carcinomas (GBC) are incidentally detected after laparoscopic cholecystectomy (LC). This study intended to analyze the effect of extended reoperation on the long-term outcome of patients with pT1b/T2 GBC who had initially undergone LC. METHODS: A cohort of 203 patients who underwent R0 resection and whose pathology was pT1b or pT2 GBC was divided into 3 groups: open surgery (group I, n = 150), LC only (group II, n = 25), and initial LC and subsequent reoperation (group III, n = 28). RESULTS: Mean ages were 62.3 ± 9.6 years, 65.9 ± 11.8 years, and 57.1 ± 7.7 years in groups I, II, and III, respectively (p = 0.001). The numbers of pT1b and pT2 patients were 75 and 75 in group I, 15 and 10 in group II, and 6 and 22 in group III, respectively. Residual tumors after LC were found in none of 6 pT1b patients and 5 of 22 pT2 patients. Overall 5-year patient survival rate was 70.1 % for all-cause death and 73.5 % for tumor recurrence-associated death (76.0 % in group I, 64.0 % in group II, and 63.0 % in group III [p = 0.607]; 84.4 % in pT1b group I, 68.8 % in pT1b group II, and 83.3 % in pT1b group III [p = 0.649]; 67.6 % in pT2 group I, 50 % in pT2 group II, and 61.9 % in pT2 group III [p = 0.895]). Concurrent bile duct resection in pT2 patients did not affect survival outcomes (p = 0.601). CONCLUSIONS: No definite survival benefit from reoperation was observed in patients with pT1b lesions. Residual tumor was found in 23 % of pT2 patients after reoperation, and the survival outcomes of these patients were comparable to those of the open surgery group. Therefore, reoperation for pT1b GBC following LC can be individually indicated because its indication remains unclear, but it should be highly recommended for pT2 GBC.

Prevalence analysis of de novo hepatic steatosis following pylorus-preserving pancreaticoduodenectomy.

BACKGROUND: Prevalence of hepatic steatosis following pylorus-preserving pancreaticoduodenectomy (PPPD) is high. This study intended to reveal the prevalence and patterns of de novo hepatic steatosis following PPPD. METHODS: We investigated postoperative de novo hepatic steatosis following PPPD (n = 101) with a control group of bile duct resection (BDR) (n = 54). RESULTS: At postoperative 1 year, hepatic steatosis occurred in 21 of 82 patients (25.6%) of PPPD group and in 2 of 47 patients (4.3%) of BDR group (p = 0.001). Thereafter, at 2 to 5 years, a high prevalence of hepatic steatosis persisted in the PPPD group, but no further occurrence developed in BDR group. Once steatosis developed, it persisted until the end of the study period or patient death. Five-year cumulative incidence of hepatic steatosis was 26.7% in the PPPD group and 3.7% in BDR group (p < 0.001). Univariate analyses showed that patient sex, age, body mass index, blood lipid profile, recurrence of tumor, and diabetes did not have significant influence on the development of hepatic steatosis following PPPD. CONCLUSIONS: De novo hepatic steatosis may develop in a not negligible proportion of patients undergone PPPD. Multicenter studies with a high number of patients are needed to elucidate its pathogenesis and to find effective treatment for pancreaticoduodenectomy-associated hepatic steatosis.

Pancreatic atrophy relative to external versus internal drainage of the pancreatic duct after pylorus-preserving pancreaticoduodenectomy.

BACKGROUND: Atrophy of the pancreatic parenchyma, which occurs frequently after pylorus-preserving pancreaticoduodenectomy (PPPD), is often associated with pancreatic exocrine insufficiency. Many surgeons prefer to insert a drainage tube into the remnant pancreatic duct primarily to prevent pancreatic leakage at the pancreaticojejunostomy (PJ) after PPPD. Drainage methods vary widely but can be roughly classified as internal or external drainage. This study intended to evaluate their effects on pancreatic parenchymal atrophy following PPPD. METHODS: Fifty-seven patients who underwent PPPD were retrospectively divided into two groups, 28 who underwent external and 29 who underwent internal pancreatic drainage. External drainage tubes were removed 4 weeks after PPPD. The volume of the pancreatic parenchyma was serially measured on abdominal computed tomography (CT) scans before PPPD, as well as 7 days and 3, 6, and 12 months after surgery. Degree of pancreatic parenchymal atrophy was determined by calculating pancreatic volume relative to that on day 7. RESULTS: Univariate analysis showed that patient sex, age, body mass index, concurrent pancreatitis, pathology, and types of PJ did not significantly affect changes in pancreatic volume following PPPD. The degree of pancreatic volume atrophy did not differ significantly in the external and internal drainage groups. No patient in the external drainage group experienced drainage-related surgical complications. The incidence of PJ leak was comparable in the two groups. Postoperative pancreatic atrophy did not induce new-onset diabetes mellitus at 1 year. CONCLUSIONS: Both external and internal pancreatic drainage methods showed similar atrophy rate of the pancreatic parenchyma following PPPD.

Survival differences between Milan criteria after down-staging and De novo Milan in living donor liver transplantation for hepatocellular carcinoma.

BACKGROUND/AIMS: This study reports our experiences of adult living donor liver transplantation (LDLT) corresponding to downstaging. METHODOLOGY: Between July 1992 and April 2008, we performed 553 adult LDLTs (35.1%, 553/1575) for HCC. Sixty-five patients was not treated before LDLT and belonged to Milan criteria, classified as De novo Milan group (De novo-M); 22 HCC patients did not meet Milan criteria initially, but subsequently met the criteria after downstaging, classified as artificial Milan group (Artificial-M). The evaluation of downstaging was based on preoperative CT scan and explanted liver biopsy, and excluded the patients having unclear treatment history on analysis. RESULTS: Artificial-M showed significantly less Child C patients (25%) than De novo-M (64.5%) (0.037). Artificial-M had greater tumor burden than De novo-M in maximal tumor size (2.5 +/- 1.2 versus 2.2 +/- 0.95 cm), sum of tumor diameter (3.4 +/- 1.4 versus 2.4 +/- 1.0 cm), number of nodules (1.8 +/- 0.9 versus 1.2 +/- 0.5), respectively. Five-year cumulative survival was not different between Artificial-M and De novo-M (83.9% versus 93.9%), but 5-year disease free survival were significantly different (71.1% versus 96.5%) (p = 0.0016). CONCLUSIONS: Five year overall survival rates after LDLT were good in both groups. However, stricter follow-up is necessary in Artificial-M considering greater tumor burden and higher recurrence rate compared to De novo-M.

Section 15. A desensitizing protocol without local graft infusion therapy and splenectomy is a safe and effective method in ABO-incompatible adult LDLT.

BACKGROUND: The use of rituximab (Rit) to prevent antibody-mediated rejection (AMR) of ABO-incompatible (ABOi) adult living donor liver transplants (ALDLTs) has raised questions about the role of local graft infusion therapy (LGIT) and splenectomy (SPN); however, they are still regarded as essential components of the desensitization (DSZ) protocol. METHODS: The DSZ protocol consisted of plasma exchange and Rit. None of the patients underwent SPN. The patients were divided into two groups. The patients in Group I (n=20) received LGIT via the hepatic artery or portal vein. The patients in Group II (n=100) did not receive LGIT. RESULTS: One hundred twenty ABOi ALDLTs were performed from November 2008 to June 2012, and there was only one case of operative mortality (0.8%). There was no significant difference in the 3-year patient survival rates between patients receiving ABO-compatible and ABOi ALDLT (88.8% vs. 94.8%; P=0.11). LGIT catheter-related complications occurred in six patients (30.0%). There was no statistically significant difference in the 3-year patient survival rates between the groups (90.0% vs. 95.0%; P=0.26). One patient in Group 1 (0.8%) experienced AMR. Diffuse intrahepatic biliary stricture occurred in two patients (10.0%) in Group I and in five patients (5.0%) in Group II, although the difference was not statistically significant (P=0.11). The incidence of biliary stricture was similar in both groups (P=0.06), but the incidence of infection was significantly higher in Group I (P=0.03). CONCLUSION: The DSZ protocol without LGIT and splenectomy is a safe and effective method of attaining a successful outcome of ABOi ALDLT.

Biliary stricture is the only concern in ABO-incompatible adult living donor liver transplantation in the rituximab era.

BACKGROUND & AIMS: With the introduction of rituximab prophylaxis, the survival of ABO-incompatible (ABOi) adult living donor liver transplant (ALDLT) has been strikingly improved due to the decreased incidence of antibody-mediated rejection. However, biliary stricture (BS) related to ABO incompatibility remains an unresolved concern. METHODS: Excluding 105 dual graft ALDLTs, 1102 ALDLT cases including 142 ABOi recipients were included in this study. The desensitization protocol for overcoming the ABO blood group barrier comprised pretransplant plasma exchange, and rituximab (300-375 mg/m(2) BSA). RESULTS: The mean follow-up period was 34.2 ± 15.4 months. The cumulative graft and patient survival rates were comparable in the two groups. The 1- and 3-year BS-free survival rates of ABOi ALDLT were 81.5 and 79.0%, respectively, lower than those of ABOc ALDLT (87.6 and 85.7%, respectively, p=0.022). In the risk factor analysis, diameter of graft bile duct opening <5mm, antecedent acute cellular rejection, and ABO incompatibility were independent risk factors for BS. Diffuse intrahepatic biliary stricture (DIHBS) exclusively occurred in 12 patients (8.5%) receiving ABOi ALDLT. The deaths of 3 patients and 4 cases of re-transplantation were related to DIHBS. Graft and patient survival rates were significantly reduced in ABOi ALDLT recipients with DIHBS. However, we failed to identify any significant risk factors for DIHBS. CONCLUSIONS: The incidence of BS in ABOi ALDLT is higher than in ABOc, mainly due to the fact of DIHBS which significantly affected survival outcomes. To predict and prevent DIHBS, we need further studies to identify significant risk factors.

A comparative study regarding the effect of an intraperitoneal anti-adhesive agent application in left-liver living donors.

BACKGROUNDS/AIMS: After left-sided hepatectomy due to a living donor, the stomach can become adhered to the hepatic cut surface. An unwanted gastric stasis can occur. For prevention of such gastric adhesion and laparotomy-associated adhesive ileus, some anti-adhesive agents have been developed for intra-abdominal application. The purpose of this study is to evaluate the effect of an intraperitoneal anti-adhesive agent application compared with a historical control group. METHODS: The study group consisted of 220 consecutive living donors who donated a left-liver graft during the time period between January 2006 and December 2011. The anti-adhesive agent which was used was composed of sodium hyaluronate and sodium carboxymethyl cellulose. The historical control group which used no anti-adhesive agent included 220 consecutive left-liver donors during the time period between January 1998 and December 2004. RESULTS: An overt gastric stasis which required fasting was observed in 5 subjects (2.3%) in the study group and in 7 subjects (3.2%) in the control group (p=0.77). An additional work-up to determine gastric stasis or prolonged ileus was performed in 17 (7.7%) and 22 (10%) donors, respectively (p=0.51). Only one donor in the control group underwent a laparotomy for an intestinal obstruction. No clinical factors such as patient age, sex, body mass index, remnant right liver proportion, shape of skin incision, and duration of surgery were significant risk factors of gastric stasis or prolonged ileus. No harmful side-effects of the anti-adhesive agent were identified. CONCLUSIONS: As a result of this study, the application of an anti-adhesive agent could not be proved as to be effective for prevention of gastric stasis and postoperative ileus. A further randomized and controlled study will be required to demonstrate the real benefits of an anti-adhesive application in left-liver living donors.

Assessment of right liver graft perfusion effectiveness between one and two-catheter infusion methods.

BACKGROUNDS/AIMS: Conventional graft perfusion method using one small-caliber catheter takes a relatively long time for right liver graft perfusion, thus some modification is needed. In this study, we intended to assess the effectiveness of right liver graft perfusion methods through comparison of different infusion catheters. METHODS: The study consisted of two parts including one bench experiment to obtain data of hydraulic infusion and one clinical trial of 40 cases on graft perfusion with one- versus two-catheter infusion methods. These two graft infusion methods were compared in terms of the perfusion time and washing-out efficiency. RESULTS: At bench experiment, the infusion flow rate and infusion pressure were 3.3 ml/sec and 1.9 cmH20 in one blood transfusion catheter group, and 11.7 ml/sec and 3.1 cmH20 in single transurethral resection of prostate irrigation catheter group, and 6.6 ml/sec and 2.0 cmH20 in two blood transfusion catheters group, respectively. In clinical trial with 40 right liver grafts, two-catheter group had a shorter graft portal perfusion time for the first 2 L of histidine-tryptophan-ketoglutarate (HTK) solution than the conventional one-catheter group (375±25 seconds vs. 662±34 seconds; p=0.001) and a lower rate of incomplete blood washing-out after the initial 2 L portal perfusion (40% vs. 85%; p=0.03). CONCLUSIONS: The two-catheter infusion method appears to be more effective than the conventional one-catheter infusion method for right liver graft perfusion at the back table. Large size of right liver grafts seems to be its good indication.

Tailored long-term immunosuppressive regimen for adult liver transplant recipients with hepatocellular carcinoma.

BACKGROUNDS/AIMS: There are few guidelines for tailored immunosuppressive regimens for liver transplantation (LT) recipients with hepatocellular carcinoma (HCC). To establish long-term immunosuppressive regimens suitable for Korean adult LT recipients, we analyzed those that were currently in use at a single high-volume institution. METHODS: This cross-sectional study comprises three parts including review of the immunosuppressive regimens used to manage 2,147 adult LT outpatients, review of LT recipients who were diagnosed of HCC at LT, and review of LT recipients who suffered from HCC recurrence. RESULTS: In 1,000 adult LT recipients who were living more than 5 years with no adverse events, 916 received a calcineurin inhibitor (CNI)-based therapy (CNI only in 520; CNI with mycophenolate mofetil [MMF] in 396) and 84 were receiving an MMF-based therapy (MMF only in 45; MMF with minimal CNI in 39). Tacrolimus was preferred over cyclosporine for both monotherapy and combination therapy along the passage of posttransplant period. There was no difference in selection of immunosuppressants, target blood concentration, and rate of combination therapy between LT recipients with and without HCC, except for the first 1 year. Sirolimus-based regimens were applied in 21 patients who showed HCC recurrence. Sorafenib was often used after conversion to sirolimus. CONCLUSIONS: Tailored immunosuppressive regimen covering the long-term posttransplant period should be established after consideration of individualized patient profiles including HCC.

Living donor liver transplantation for patients with alcoholic liver disease.

BACKGROUNDS/AIMS: Since most transplantation studies for alcoholic liver disease (ALD) were performed on deceased donor liver transplantation, little was known following living donor liver transplantation (LDLT). METHODS: The clinical outcome of 18 ALD patients who underwent LDLT from Febraury 1997 to December 2004 in a large-volume liver transplantation center was assessed retrospectively. RESULTS: The model for end-stage liver disease score was 23±11, and mean pretransplant abstinence period was 16±13 months, with 14 (77.8%) patients being abstinent for at least 6 months. Graft types were right lobe grafts in 11, left lobe grafts in 2 and dual grafts in 5. Graft to recipient body weight ratio was 0.94±0.16. The relapse rates in patients who did and did not maintain 6 months of abstinence were 7.1% and 50%, respectively (p=0.097). Younger recipient age was a significant risk factor for alcohol relapse (p=0.027). Five recipients with antibody to hepatitis B surface antigen (HBsAg) received core antibody-positive liver graft, but two of them showed positive HBsAg seroconversion. Overall 5-year patient survival rate following LDLT was 87.8%, with a 5-year relapse rate of 16.7%. CONCLUSIONS: Pretransplant abstinence for 6 months appears to be benefical for preventing posttransplant relapse. Life-long prophylactic measure should be followed after use of anti-HBc-positive liver grafts regardless of hepatitis B viral marker status of the recipient.