Pure laparoscopic donor hepatectomy: Experience of 556 cases at Seoul National University Hospital.

Pure laparoscopic donor hepatectomy (PLDH) has become a routine procedure at Seoul National University Hospital, and the pure laparoscopic method is now being applied to liver recipients as well. This study aimed to review the procedure and outcomes of PLDH to identify any areas that required improvement. Data from 556 donors who underwent PLDH between November 2015 and December 2021 and their recipients were retrospectively reviewed. Among these, 541 patients underwent pure laparoscopic donor right hepatectomy (PLDRH). The mean hospital stay of the donor was 7.2 days, and the rate of grade I, II, IIIa, and IIIb complications was 2.2%, 2.7%, 1.3%, and 0.9%, respectively, without any irreversible disabilities or mortalities. The most common early and late major complications in the recipient were intraabdominal bleeding (n = 47, 8.5%) and biliary problems (n = 198, 35.6%), respectively. Analysis of the PLDRH procedure showed that operative time, liver removal time, warm ischemic time, Δhemoglobin%, Δtotal bilirubin%, and postoperative hospital stay decreased significantly as the number of cases accumulated. In conclusion, the operative outcomes of PLDRH improved as the number of cases increased. However, continuous caution is needed because major complications still occur in donors and recipients even after hundreds of cases.

Accidental ABO-incompatible pediatric liver transplantation with blood group antigen immune and operational tolerance: a case report with 21 years of follow-up.

Liver transplantation is a critical procedure for patients with end-stage liver disease, but it is often hindered by ABO-incompatibility between the donor and recipient, which can lead to immediate humoral rejection. We present a unique case involving a 10-month-old patient who, by accident, received an ABO-incompatible partial liver transplant from a type A mother without undergoing desensitization. Remarkably, during a 21-year follow-up period, the patient exhibited no signs of humoral or graft rejection, despite nonadherence to medication. This case highlights the possibility of dual tolerance in pediatric ABO-incompatible liver transplantation and provides insights into immune tolerance mechanisms, with implications for enhancing patient care and reducing healthcare costs. Further research is necessary to clarify these mechanisms and to evaluate the long-term durability of tolerance in pediatric transplant recipients.

Immune Reconstitution Inflammatory Syndrome and Drug-Induced Liver Injury During Treatment of Disseminated Tuberculosis in a Liver Transplant Recipient: A Case Report.

Studies have shown that tuberculosis (TB) incidence is 20 to 70 times higher in solid organ transplantation recipients. Immunosuppression makes transplant recipients more vulnerable to infection and can interfere with the treatment. Our case report describes a patient who experienced immune reconstitution inflammatory syndrome (IRIS) and drug-induced liver injury (DILI) related to TB medications for disseminated pulmonary and hepatic TB. In addition to anti-TB medication, the patient received a high-dose steroid for IRIS and a change of anti-TB medication to a secondary regimen for DILI. This case illustrates various responses to anti-TB treatment in a liver transplant recipient and the necessity of closely monitoring immune suppression and liver function.

Recurrence in patients with totally necrotic nodules of hepatocellular carcinoma after liver transplantation: "totally" an inaccurate description.

Purpose: Total necrosis of hepatocellular carcinoma (HCC) achieved via locoregional treatment (LRT) is considered to indicate a lack of tumor viability. Nonetheless, there is insufficient evidence of recurrence after liver transplantation (LT) in patients with such a status. The aim of this study was to investigate the prognosis of patients diagnosed with totally necrotic nodules upon explant hepatectomy after LT. Methods: We conducted a retrospective study of patients diagnosed with totally necrotic nodules after LT for HCC. A total of 165 patients with HCC who underwent living- or deceased-donor LT from 2000 to 2020 in our hospital were included. Results: A total of 5 patients (3.0%) exhibited HCC recurrence during a median follow-up of 84 months (range, 4-243 months) after LT. The 5-year overall and recurrence-free survival rates of these patients were 92.8% and 92.2%, respectively. Four patients in the HCC-recurrence group (80.0%) died even after further treatment, including transarterial chemoembolization, surgery, and systemic treatment. Both univariate and multivariate analyses of clinicopathological factors identified a maximum diameter of the totally necrotic nodules of >5 cm as the only factor associated with tumor recurrence following LT (P = 0.005 and P = 0.009, respectively). Conclusion: Total necrosis of HCC via LRT yielded excellent survival outcomes for patients undergoing LT. Nevertheless, patients with large tumors should be considered at high risk of recurrence after LT, suggesting the need for their active surveillance during the follow-up period.

Posttransplant sequential adrenal and spine metastasis of hepatocellular carcinoma responsive to combined regorafenib and radiotherapy: a case report.

Adrenal and spinal metastases of hepatocellular carcinoma (HCC) are rare entities with significant morbidity and mortality, particularly after liver transplantation (LT). We report a case of a 49-year-old man who underwent LT for hepatitis B-related end-stage liver disease and HCC (single 4.5 cm lesion [T1N0], without vascular invasion) in 2016. Eighteen months later, adrenal metastasis and hepatitis B seropositive conversion were developed with normal serum tumor. Adrenal metastasis was treated with radiation therapy (RT) and hepatitis B showed spontaneous seronegative conversion. However, 35 months later, spinal metastasis occurred with elevation of the protein induced by vitamin K absence or antagonist-II (PIVKA-II) level (197 mAU/mL), along with hepatitis B seropositive conversion. After sorafenib, sequential regorafenib with RT led to partial response of the spinal lesions, along with hepatitis B seronegative conversion and normal PIVKA-II levels. After 9 months of regorafenib combined with RT, two recurrent lesions were found, as well as hepatitis B seropositive conversion and lesions were treated with transarterial chemoembolization. The patient survived for more than 71 months after LT and 53 months after recurrence under various combinations of therapy. Combined systemic and locoregional therapies can be a treatment option for HCC recurrence, even in LT patients.

Portal vein reconstruction in pediatric liver transplantation using end-to-side jump graft: A case report.

Attenuated portal vein (PV) flow is challenging in pediatric liver transplantation (LT) because it is unsuitable for classic end-to-end jump graft reconstruction from a small superior mesenteric vein (SMV). We thus introduce a novel technique of an end-to-side jump graft from SMV during pediatric LT using an adult partial liver graft. We successfully performed two cases of end-to-side retropancreatic jump graft using an iliac vein graft for PV reconstruction. One patient was a 2-year-old boy with hepatoblastoma and a Yerdel grade 3 PV thrombosis who underwent split LT. Another patient was an 8-month-old girl who had biliary atresia and PV hypoplasia with stenosis on the confluence level of the SMV; she underwent retransplantation because of graft failure related to PV thrombosis. After native PV was resected at the SMV confluence level, an end-to-side reconstruction was done from the proximal SMV to an interposition iliac vein. The interposition vein graft through posterior to the pancreas was obliquely anastomosed to the graft PV. There was no PV related complication during the follow-up period. Using a jump vascular graft in an end-to-side manner to connect the small native SMV and the large graft PV is a feasible treatment option in pediatric recipients with inadequate portal flow due to thrombosis or hypoplasia of the PV.

Total robot-assisted recipient's surgery in living donor liver transplantation: First step towards the future.

Lee and colleagues describe a groundbreaking total robot-assisted explant hepatectomy followed by robotic engraftment for a patient requiring a living donor liver transplant. This report represents a crucial step towards implementing robot-assisted liver transplantation, a cutting-edge surgical technique that could change the surgical trend in recipient surgery for liver transplantation.

Initial outcome of external biliary drainage in living donor liver transplantation with pure laparoscopic donor hepatectomy.

Biliary complications after living donor liver transplantation (LDLT) are the most common and intractable complications due to both surgical and nonsurgical factors. External biliary drainage (EBD), a surgical option to prevent biliary complications, has recently been adopted in the era of pure laparoscopic donor right hepatectomy, which may result in increased bile duct problems in the recipients. This study retrospectively reviewed the patients who underwent LDLT with duct-to-duct anastomosis between July 2017 and October 2020 to analyze the initial outcomes of EBD and to compare the incidence of biliary complications in adult LDLT recipients who underwent duct-to-duct anastomosis with or without EBD. Only patients who underwent pure laparoscopic donor hepatectomy were included in this study. The patients were divided into 2 groups according to the application of EBD. The median follow-up period was 28.5 months. The overall incidence of Clavien-Dindo grade IIIa biliary complications was 35.0% (n=14) in the EBD group and 50.7% (n=76) in the non-EBD group ( p = 0.08). The incidence of biliary leakage was 0% in the EBD group and 15.3% in the non-EBD group ( p = 0.01). The EBD-related complication rate, that is, involving retraction, accidental removal, and dislocation, was 40.0%. EBD implementation is effective in preventing biliary leakage after LDLT with a graft procured using the pure laparoscopic donor right hepatectomy method with duct-to-duct biliary anastomosis. However, efforts should be made to prevent EBD-related complications. Further studies are needed to establish appropriate selection criteria for EBD.

Swine Partial Liver Transplantation Model for Practicing Living Donor Liver Transplantation Based on a New Liver Segmentation Method.

BACKGROUND: Living donor liver transplantation (LDLT) is one of the most technically demanding and complicated procedures. However, unlike deceased donor liver transplantation, there is no suitable animal model for practicing LDLT. Herein, we propose a new liver segmentation method and a feasible pig LDLT model for practicing for LDLT in humans. METHODS: Four Landrace pigs weighing 25, 25, 27, and 28 kg were used as donors and recipients to establish a partial liver transplantation model. Partial liver transplantation was performed using a right liver and a left liver, respectively, based on a new segmentation system compatible with that of humans. RESULTS: We established a new segmentation system for porcine liver transplantation and a partial liver transplantation model. For right liver transplantation, 91 and 142 min were required to operate on the donor and recipient, respectively; for left liver transplantation, 57 and 104 min were required to operate on the donor and recipient, respectively. All pigs that underwent partial liver transplantation remained alive until the operation was completed. CONCLUSIONS: It is expected that this new pig model based on the new segmentation system will be suitable as an educational tool for LDLT training and will replace the existing animal models for partial liver transplantation.

Posttransplant renal replacement therapy is an alarm signal for survival outcomes in pediatric liver transplantation.

BACKGROUND: The impact of renal replacement therapy (RRT) on the long-term survival outcomes of pediatric liver recipients remains controversial. METHODS: A total of 224 patients aged <18 years, who underwent liver transplantation (LT), were divided into two groups: patients who underwent renal replacement therapy (RRT) (group R, n = 25, 11.2%) and those who did not (group N, n = 199, 88.8%). The posttransplant patient survival outcomes according to RRT use constituted the primary end-point. RRT was initiated preoperatively in 12 patients (48.0%) and postoperatively in 13 [early: <6 months after LT (n = 5, 20.0%) and late: ≥6 months after LT (n = 8, 32.0%)]. The indications for RRT included liver disease involving the kidney (44.0%) and hepatorenal syndrome (56.0%). RESULTS: The age at the time of LT (71.6 vs. 19.1 months) was higher, the pediatric end-stage liver disease score was lower (9.9 vs. 21.2), and the duration of hospitalization posttransplantation (41.0 vs. 27.0 days) was longer, while the rates of hepatic artery thrombosis (8.0% vs. 3.5%) were higher in group R (p < .05). The number of patients (60.0% vs. 93.0%; p < .001) and graft survival rates (68.0% vs. 93.0%; p < .001) were significantly lower in group R. Multivariate analysis revealed that posttransplant RRT and hepatic artery complications were risk factors for patient survival outcomes. Renal function was recovered in 7 patients (28.0%) in group R, and 9 (36.0%) eventually underwent kidney transplantation. CONCLUSION: The survival outcomes of children requiring posttransplant RRT were significantly worse than those of children, who did not undergo RRT. Physicians should pay meticulous attention to patients requiring post-LT RRT.

The fate of donor-type ABO blood group antigen expression in liver grafts in ABO-incompatible adult living donor liver transplantation.

BACKGROUND/PURPOSE: Donor-type ABO blood group antigens (dABOAgs) have been detected in ABO-incompatible adult living donor liver transplantation (ABOi ALDLT) grafts, but their fate and role in ABOi ALDLT rejection remain uncertain. METHODS: The 0-day, <1-month, and 1-year serial liver graft biopsies from 30 ABOi ALDLT recipients were retrospectively evaluated. ABO antigen expression was quantitatively and serially measured by the mean number of positively stained vascular structures (endothelium of the capillaries, arteries, hepatic veins, and portal veins) within the portal tracts (sS). RESULTS: The dABOAg sS counts of 0-day, <1-month, and 1-year liver graft biopsies (32.3, 20.8, and 20.6, respectively) decreased significantly (p < .001). Early rejection in the <1-month biopsy was observed in 8/30 (26.7%) recipients, four (13.3%) of whom showed antibody-mediated rejection. The sS counts tended to rebound in grafts showing early rejection, with minimal changes from the 0-day to <1-month period, but increased to pre-transplantation levels after 1 year, compared to that in grafts without early rejection (36.0, 20.4, 19.6 vs. 23.7, 21.9, 23.0, respectively; p = .040). CONCLUSIONS: While dABOAg expression decreased after ABOi ALDLT, recipients showing early rejection showed sustained graft dABOAg expression. Therefore, dABOAg expression may be involved in the mechanism of accommodation in ABOi transplantation.

Pure laparoscopic vs open right hepatectomy in patients with hepatocellular carcinoma: A propensity score-matched analysis.

BACKGROUND/PURPOSE: Since minimally invasive surgery has been incorporated in overall surgery, pure laparoscopic technology is involved in most hepatectomies, including right hepatectomy, in patients with hepatocellular carcinoma (HCC). However, its feasibility and safety in right hepatectomy are still controversial owing to the limited literature. This study aimed to compare the short- and long-term outcomes of pure laparoscopic right hepatectomy (PLRH) with those of open right hepatectomy (ORH) in patients with HCC. METHODS: The prospectively collected medical records of 327 patients with HCC who underwent right hepatectomy between January 2010 and April 2020 at Seoul National University Hospital were retrospectively reviewed. We performed 1:1 propensity score matching between the PLRH and ORH groups. The primary end point was short-term outcomes, including hospital stay, blood loss, and morbidity; the secondary end point was long-term outcomes, including overall and recurrence-free survival. RESULTS: Forty-nine patients were included in each group. Patients who underwent PLRH had a shorter postoperative hospital stay than those who underwent ORH (12.2 vs 8.9 days; P < .001). The requirement for blood transfusion was significantly lower in the PLRH group than in the ORH group (10.2% vs 2.0%; P = .010). The operative time (P = .479) and proportion of major complications (P = .487) were comparable between the groups. There were no significant differences in overall survival (P = .524) and the recurrence-free survival rate (P = .576) between the groups. CONCLUSIONS: Postoperative outcomes, including oncological outcomes, were comparable between PLRH and ORH, showing that PLRH can be a safe and feasible option to replace ORH in patients with HCC.

Anatomical classification and clinical outcomes of biliary strictures in living donor liver transplantation using right liver grafts.

This study aimed to classify the anatomical types of biliary strictures, including intrahepatic biliary stricture (IHBS), after living donor liver transplantations (LDLTs) using right liver grafts and evaluate their prognosis. Among 692 adult patients who underwent right liver LDLT, 198 recipients with biliary strictures (28.6%) were retrospectively reviewed. Based on data obtained during the first cholangiography, the patients' biliary strictures were classified into the following three types according to the levels and number of branches involved: Types 1 (anastomosis), 2 (second-order branch [a, one; b, two or more; c, extended to the third-order branch]), and 3 (whole graft [a, multifocal strictures; b, diffuse necrosis]). IHBS was defined as a nonanastomotic stricture. Among the 198 recipients with biliary strictures, the IHBS incidence rates were 38.4% ( n = 76). The most common type of IHBS was 2c ( n = 43, 56.6%), whereas Type 3 ( n = 10, 13.2%) was uncommon. The intervention frequency per year significantly differed among the types (Type 1, 2.3; Type 2a, 2.3; Type 2b, 2.8; Type 2c, 4.3; and Type 3, 7.2; p < 0.001). The intervention-free period for more than 1 year, which was as follows, also differed among the types: Type 1, 84.4%; Type 2a, 87.5%; Type 2b, 86.7%; Type 2c, 72.1%; and Type 3, 50.0% ( p = 0.048). The graft survival rates of Type 3 (80.0%) were significantly lower than those of the other types ( p = 0.001). IHBSs are relatively common in right liver LDLTs. Although Type 3 IHBSs are rare, they require more intensive care and are associated with poorer graft survival rates than anastomosis strictures and Type 2 IHBS.

Early experiences with developing techniques for pure laparoscopic explant hepatectomy in living donor liver transplantation.

In recent years, laparoscopic techniques for liver resection or living donor hepatectomy have become common surgical methods. However, reports on laparoscopic surgeries for recipients are lacking. Our center has launched the minimally invasive living donor liver transplantation (LDLT) program in March 2020, which is led by two surgeons who are experienced in laparoscopic surgeries. Recently, we reported our first successful pure laparoscopic recipient explant hepatectomy and the first laparoscopic explant hepatectomy and robotic-assisted graft implantation. In this article, we introduce a series of minimally invasive surgical cases that were conducted by a single experienced surgeon to share our early experiences leading to our recent successes. We included 10 cases performed from June 2020 to May 2021 in our initial attempt at laparoscopic explant hepatectomy, graft implantation using midline incision, and robotic-assisted graft implantation surgery. The first four cases required open conversion during the liver mobilization process because of bleeding. The next two cases required open conversion to facilitate portal vein and hepatic artery division. We successfully performed pure laparoscopic explant hepatectomy in the last four cases. For the last case, we attempted to perform graft implantation using a robotic system, but bleeding required open conversion. All patients recovered without any significant acute postoperative problems and were discharged within 2 weeks. All 10 patients were followed up at outpatient clinics, and only one of the 10 patients had a late complication of LDLT. This study has shown that the minimally invasive approach in LDLT may be conducted safely without significant complications if it is performed by highly experienced surgeons working in high-volume centers.

Pure Laparoscopic Versus Open Right Hepatectomy in Living Liver Donors: Graft Weight Discrepancy.

BACKGROUND Accurate volumetric evaluation of donors' livers before surgery is crucial for successful living-donor liver transplantation. However, there are few studies on the volumetric evaluation in the recently popularized pure laparoscopic donor hepatectomy method, in contrast to the number of studies for conventional donor hepatectomy. We aimed to analyze the difference between estimated graft weight and actual graft weight in pure laparoscopic donor right hepatectomy (PLDRH) and conventional donor right hepatectomy (CDRH) procedures. MATERIAL AND METHODS The medical records of 612 donors who underwent right hepatectomy in living-donor liver transplantation between January 2014 and December 2020 were retrospectively reviewed. The CDRH group targeted patients from January 2014 to October 2015, and the PLDRH group targeted patients from March 2016 to December 2020. RESULTS There were 119 and 376 donors who underwent CDRH and PLDRH, respectively. Although there was no significant difference in the estimated graft weights (P=0.994) and actual graft weights (P=0.489) between the groups, the estimated graft weights were significantly higher than the actual graft weights in both groups. However, the estimated graft weight and actual graft weight showed linear correlations in both the CDRH (r=0.81, P<0.001) and PLDRH (r=0.76, P<0.001) groups, with the CDRH group having greater linearity. CONCLUSIONS The estimates of graft weight were similar between the 2 groups. However, since the actual graft weight tended to be smaller in the PLDRH group, this should be considered before surgery.

Long-Term Survival Outcomes beyond the First Year after Liver Transplantation in Pediatric Acute Liver Failure Compared with Biliary Atresia: A Large-Volume Living Donor Liver Transplantation Single-Center Study.

Pediatric acute liver failure (PALF) is a common cause of liver transplantation (LT) but showed poor post-LT outcomes. We reviewed 36 PALF patients and 120 BA patients who underwent LT in our institution. The cause of PALF was unknown in 66.7%. PALF patients were older (6.2 vs. 2.9 years) with higher PELD scores (31.5 vs. 24.4) and shorter waitlist time (15.7 vs. 256.1 days) (p < 0.01). PALF patients showed higher rates of post-transplant renal replacement therapy (RRT) (13.9% vs. 4.2%) and hepatic artery complications (13.9% vs. 0.8%), while portal vein complications rates were lower (0% vs. 10.8%), (p < 0.05). Although PALF patients showed lower 5-year survival rates (77.8% vs. 95.0 %, p < 0.01), the 5-year survival rates of patients who lived beyond the first year were comparable (96.6% vs. 98.3%, p = 0.516). The most common cause of deaths within one year was graft failure (75.0%) in PALF patients, but infection (67.7%) in BA patients. In multivariate analysis, lower body weight, hepatic artery complications and post-transplant RRT were associated with worse survival outcomes (p < 0.05). In conclusion, physicians should be alert to monitor the immediate postoperative graft dysfunction and hepatic artery complications and patients on post-transplant RRT in order to improve survival outcomes in PALF patients.

Pure laparoscopic versus open right donor hepatectomy including the middle hepatic vein: a comparison of outcomes and safety.

Purpose: Analyses on pure laparoscopy in donor hepatectomies, including the middle hepatic vein (MHV), are still scarce. This study aimed to compare the outcomes of donor right hepatectomy, including the MHV, when performed laparoscopically with conventional open surgery. Methods: Data from living donors who underwent donor right hepatectomy between January 2012 and December 2020 were retrospectively analyzed. The intraoperative and postoperative complication rates of the pure laparoscopic donor right hepatectomy (PLDRH) with MHV inclusion (PLDRHM) group were compared with the conventional open donor right hepatectomy with MHV inclusion (CDRHM) group and the PLDRH without MHV inclusion [PLDRHM(-)] group. Results: Compared to the CDRHM group, the PLDRHM group had a longer bench time (P < 0.001) and higher Δ%, calculated as [(preoperative value - postoperative value)/preoperative value] × 100, of AST (P < 0.001), ALT (P < 0.001), and total bilirubin (P = 0.023), but shorter hospital stay (P = 0.004) and a lower rate of complications (P = 0.005). Compared to the PLDRHM(-) group, the PLDRHM group had fewer male donors (P < 0.001) and a lower body mass index (P < 0.001), estimated total liver volume (P < 0.001), and real graft weight (P < 0.001). Results of laboratory changes, hospital stays, and complication rates were similar between the 2 groups. Conclusion: PLDRH with the inclusion of the MHV in selected donors and recipients is feasible and safe when performed by surgeons experienced in laparoscopic surgery, with favorable complication rates compared to CDRHM and PLDRHM(-).

Progression of a persisting mesenchymal hamartoma to intrahepatic cholangiocarcinoma 24 years after the initial diagnosis: A case report.

Mesenchymal hamartoma of the liver (MHL) is a rare benign tumor that often presents in early childhood, and it rarely occurs in adulthood. Aberrant development of the portal tract is a known cause of MHL. Although limited information is available on the natural course of MHL, malignant transformation has been reported in a few cases. Here, we report a case of a 26-year-old female with intrahepatic cholangiocarcinoma secondary to unresected MHL. The patient underwent resection of the hepatic mass, which was diagnosed as MHL at 2 years of age, due to an increase in mass size and a suspicion of malignant transformation during work-up. Histopathology confirmed intrahepatic adenosquamous carcinoma in the background of MHL, with a T2N0M0 pathological stage (stage II). The surgical margin was free from tumor cells. The patient fully recovered postoperatively and started receiving adjuvant chemotherapy. Previous case reports have only reported about the development of undifferentiated embryonal sarcoma or angiosarcoma as malignant transformation of MHL. Cases of other malignancies have not been published; however, it is difficult to rule out the occurrence of various malignancies related to the portal tract when considering the pathogenesis of the disease. To the best of our knowledge, this is the first case report of adenocarcinoma of bile duct origin secondary to MHL. This case report suggests that aggressive surgical management should be considered after the initial diagnosis of MHL.

Effect of the First Assistant on Anastomotic Leakage after Rectal Cancer Surgery with Double-Stapling Anastomosis: A Propensity Score Matching Analysis.

INTRODUCTION: Proper handling and firing of the circular stapler are important for secure anastomosis in rectal cancer surgery. This study aimed to investigate the association between the first assistant and anastomotic leakage (AL) after rectal cancer surgery with double-stapling anastomosis. METHODS: Patients with primary rectal cancer who underwent low anterior resection with double-stapling anastomosis between January 2015 and September 2019 were included. Data on clinicopathological characteristics, including the first assistant's sex and experience level, were retrospectively reviewed, and the risk factors for AL were analyzed using propensity score matching analysis. RESULTS: Among 758 rectal cancer surgeries, residents participated in 401 (52.9%) surgeries, and fellows participated in 357 (47.1%) surgeries as first assistants. After propensity score matching (n = 650), AL occurred in 5.4% (35/650). The first assistant's experience level (resident: 5.5% vs. fellow: 5.2%, p = 0.862) and sex (male: 5.4% vs. female: 4.9%, p = 0.849) were not associated with the occurrence of AL. Male sex in patients was the only significant predictive factor for AL (odds ratio = 2.804, 95% confidence interval 1.070-7.351, p = 0.036). DISCUSSION/CONCLUSION: The first assistant's sex and experience level were not associated with AL after rectal cancer surgery with double-stapling anastomosis. These findings may justify resident participation in rectal cancer surgeries in which circular staplers are used.