The graft-to-recipient weight ratio (GRWR) threshold of 0.80% has long been used to guide graft selection in adult living donor liver transplantation (LDLT) as a pragmatic surrogate for graft adequacy. However, expanding use of donor-sparing left liver grafts and advances in perioperative management have challenged the universality of this cutoff. This review re-examines the relevance of the 0.80% GRWR threshold in modern adult LDLT, focusing on the evolving pathophysiology of small-for-size syndrome, the role of portal hyperperfusion and secondary hepatic arterial hypoperfusion mediated through the hepatic arterial buffer response, and the clinical impact of hemodynamic monitoring and inflow modulation. We summarized surgical and pharmacologic strategies to optimize portal and arterial inflow and proposed practical hemodynamic targets (e.g., portal venous flow < 5 mL/min per gram graft and portal venous pressure < 20 mmHg with preserved hepatic arterial inflow). To provide real-world context, the authors integrated original data from their institutional left-graft LDLT cohort (n = 202, median GRWR 0.72%, range 0.39%-1.48%), including recipients with GRWR < 0.80% (n = 152, 75.2%) and < 0.60% (n = 44, 21.8%). Small-for-size syndrome occurred in 56.9% of recipients. GRWR < 0.80% was not associated with the incidence of small-for-size syndrome (60.5% vs. 46.0%, P = 0.102) or in-hospital mortality (8.6% vs. 6.0%, P = 0.765), and long-term survival was comparable across GRWR groups when portal inflow was controlled and hepatic arterial perfusion preserved. Overall, GRWR remains useful for risk stratification but should not function as an absolute cutoff, rather a physiology-driven, hemodynamic-guided strategy may better define graft adequacy in modern adult LDLT.

Robotic surgery was recently introduced as a promising tool in liver transplantation, offering improved precision, ergonomics, and magnified 3D visualization. To our knowledge, this article reports the first fully robotic dual-graft living donor liver transplantation (LDLT) in the world, a surgical procedure not yet widely adopted due to its complexity, even when performed in open surgery and mastered in very few centers worldwide. A 62-year-old woman with end-stage liver disease due to hepatic schistosomiasis (MELD 23) underwent fully robotic dual-graft LDLT. Two related donors provided left-lobe grafts, both retrieved through a pure robotic donor hepatectomy approach, enabling adequate graft volume when a single donor graft was not feasible. The recipient operation duration was 12 hours, with warm ischemia time of 46 minutes for the first graft and 36 minutes for the second one. The total implanted graft weight was 524 g with an actual combined graft-to-recipient weight ratio of 0.74%. The recipient experienced no early allograft dysfunction or surgical complications and was discharged with excellent graft function. This case shows the feasibility of fully robotic dual-graft LDLT in carefully selected patients when a single donor graft is insufficient and no other suitable donor is available.

Background:Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related mortality worldwide. With the aging population, more people above the age of 65 may become liver transplant (LT) candidates. This study aims to evaluate the outcomes of LT in patients over 65 years of age with HCC.Methods:Using our electronic medical record system, we collected data of patients, who underwent LT, from January 2001 to December 2022, at our hospital. We included patients who underwent LT and had HCC.Results:Two hundred and forty-four patients with HCC were included in the study with a mean age of 59 (SD 9) years; 74 (30%) were female. The maximum diameter of HCC was 28 mm (SD 15). The median time between HCC diagnosis and LT was 226 (IQR 79-435) days. In total, 178 (73%) patients were 65 years or less, while 66 (27%) were above 65 years. Majority of patients had LDLT (74%). Incidental HCC was found in 19 (8%) patients. 58 (24%) were out of the Milan Criteria. A total of 129 (53%) received treatment for HCC prior to the transplant. The most common pre-transplant treatment was RFA in 59 patients (45%), followed by TACE in 37 (28%) patients. The in-hospital mortality rate was 5%. The Comprehensive Complication Index (TM) (CCI (TM)) was 22.6 (IQR 8.7-39.7). The overall survival rates at 1, 2, 3, and 5 years were 92%, 88%, 86%, and 89%, respectively.Conclusion:Although lower than younger recipients, patients older than 65 years of age with HCC have an excellent outcome post-LT. Age alone should not discourage transplant centers from considering patients with HCC for transplantation.

Background/Objectives: Acute-on-chronic liver failure (ACLF) is a severe syndrome in chronic liver disease (CLD) patients, characterized by multi-organ failure and high mortality. Living donor liver transplantation (LDLT) is vital in donor-scarce areas. This study compares baseline characteristics, perioperative complications, and long-term survival between ACLF and non-ACLF patients, emphasizing etiology, ACLF grading, and graft factors. Methods: Data from a prospective registry of 591 adult LDLT recipients (2019-2023) were analyzed. ACLF was defined by EASL-CLIF (multi-organ failure, grades 1-3) and APASL (jaundice/coagulopathy with complications) criteria, evaluated at initial assessment and within 24 h pre-LDLT. Results: ACLF patients (n = 101, 17.1%) showed higher MELD-Na (27 vs. 20, p < 0.001), bilirubin (6.84 vs. 1.75 mg/dL, p < 0.001), creatinine (108 vs. 70.5 μmol/L, p < 0.001), metabolic/genetic etiologies (9.9% vs. 2.8%, p = 0.001), and chronic kidney disease (23.7% vs. 8.1%, p < 0.001), and lower HCC rates (11.8% vs. 29.6%, p < 0.001). GRWR was marginally lower in ACLF patients (0.59 vs. 0.66, p = 0.10). The ACLF group had elevated infection (27.7% vs. 10.4%, p < 0.001), bleeding (14.9% vs. 6.3%, p = 0.004), and biliary complications (15.8% vs. 7.8%, p = 0.010), with longer ICU (5 vs. 3 days, p < 0.001) and hospital stays (33.66 vs. 20.7 days, p = 0.036). Five-year overall survival was reduced in ACLF patients (log-rank p = 0.001), worsening with grade (EASL-CLIF grade 3: 55% vs. 81% for no ACLF, p = 0.002). Graft survival was also lower (75% vs. 85%, p = 0.02). Multivariable analysis identified chronic kidney disease as an independent mortality predictor (HR 2.09, 95% CI 1.11-3.95, p = 0.023). Conclusions: LDLT for ACLF involves higher perioperative risks and poorer long-term survival than non-ACLF patients, with outcomes deteriorating by ACLF grade. Chronic kidney disease independently predicts mortality. Timely LDLT is essential in donor-limited regions.

BACKGROUND:There is no consensus on the use of preoperative biliary drainage for resectable perihilar cholangiocarcinoma. This retrospective cohort study aimed to explore the association of biliary drainage with postoperative mortality and morbidity. METHODS:This retrospective observational cohort study included patients who underwent resection of histologically confirmed perihilar cholangiocarcinoma from the Perihilar Cholangiocarcinoma Collaboration Group database across 27 Western hepatobiliary centres (2000-2022). To correct for baseline differences between patients who did or did not undergo drainage, propensity score weighting was applied. Outcomes were compared using propensity score-weighted regression and multivariable analysis. RESULTS:Overall, 2067 patients were included, of whom 350 (16.9%) did not undergo biliary drainage. Before propensity score weighting, patients who did not undergo drainage were less likely to have Bismuth III-IV disease (297 (78.9%) versus 1448 (84.3%); P < 0.001), had lower median bilirubin levels (12.0 versus 85.5 µmol/l; P < 0.001), and a higher proportion had left hepatectomies (150 (42.9%) versus 454 (26.4%); P < 0.001). After propensity score-weighted regression analysis, patients in the drainage group were more likely to experience major postoperative complications (odds ratio 1.43, 95% confidence interval 1.04 to 1.95; P = 0.027) and posthepatectomy liver failure (odds ratio 2.12, 1.25 to 3.58; P = 0.005). In multivariable analysis, only posthepatectomy liver failure remained significant (odds ratio 2.13, 1.29 to 3.54; P = 0.003). CONCLUSION:In this retrospective propensity score weighting analysis, preoperative biliary drainage was associated with a higher incidence of posthepatectomy liver failure in resectable perihilar cholangiocarcinoma. These findings suggest that a subgroup of patients with perihilar cholangiocarcinoma can be operated safely without biliary drainage. The indication for preoperative biliary drainage should be considered on an individual basis.

OBJECTIVE:To compare short-term outcomes between open and fully robotic adult recipient living donor liver transplantation (LDLT). SUMMARY BACKGROUND DATA:LDLT remains a challenging procedure, traditionally performed using the open approach. Recent advancements in robotic surgery offer potential benefits, including enhanced precision, and reduced invasiveness. METHODS:This study compared two adult-to-adult recipient LDLT groups: 453 open cases and 54 fully robotic cases. Multivariable linear regression analysis was conducted to identify independent predictors of morbidity, as captured by the Comprehensive Complication Index (CCI). RESULTS:Robotic recipient liver transplantation was associated with lower median blood loss (650 vs. 2000 mL, P <0.001), shorter ICU (3 vs. 5 d, P <0.001) and hospital stay (14 vs. 20 d, P =0.030), and fewer infection rates (9.3% vs. 42.8%, P <0.001), when compared with open. The CCI was significantly lower in the robotic group (15.0 vs. 20.9, P =0.045). Graft survival at 6 months was 98.1% in the robotic vs. 91.8% in the open group ( P =0.080), while recipient survival was superior in the robotic group (100% vs. 91.8%, P =0.040). CONCLUSIONS:Fully robotic recipient LDLT is feasible and safe, with potential benefits including reduced morbidity, faster recovery, and shorter hospital stay. These findings support broader adoption of robotic techniques in liver transplantation, pending further cost-effectiveness studies and randomized controlled trials.

OBJECTIVES:Variability in right and left hemiliver drainage volumes of the middle hepatic vein is of special relevance in living donor liver partitioning. Here, we present a comprehensive classification of middle hepatic vein drainage encompassing func-tional and anatomic components with special reference to middle hepatic vein management in adult living donor liver transplantation. MATERIALS AND METHODS:We evaluated 153 living donor livers among 100 cases of living donor liver transplantation. With 3-dimensional virtual venous reconstructions and maps, we addressed (1) hepatic venous dominance in the total liver, (2) middle hepatic vein/hemiliver-territorial belonging, (3) middle hepa-tic vein drainage contribution to right and left hemilivers based on middle hepatic vein/hemiliver-congestive volume index, and (4) middle hepatic vein anatomic branching patterns. RESULTS:With an established clinical threshold of 30% to 40% middle hepatic vein-congestive volume index for graft selection, a strong correlation between venous dominance, hemiliver belonging, and congestive volume index in overlap with anatomic branching classification was demonstrated. Functional middle hepatic vein variants b and c in overlap with middle hepatic vein branching types A and C implicated middle hepatic vein reconstruction/inclusion in right/left hemiliver grafts. Functional middle hepatic vein variant a (analog to middle hepatic vein branching type B) exhibited safe small congestive drainage volumes in both hemilivers. CONCLUSIONS:The proposed middle hepatic vein classification addressed a triple correlation between hepatic vein (total liver volume) dominance and middle hepatic vein (hemiliver volume) belonging related to the middle hepatic vein-congestive volume index in right and left hemiliver as follows: (1) categorize functional middle hepatic vein variants based on congestion risk, (2) identify the left hepatic vein/left hemiliver non-congestive volume index as an additional key parameter in right graft selection, and (3) represent a predictive guide for middle hepatic vein management in right/left graft living donor liver transplantation.

Objectives: Computed tomography and magnetic resonance cholangiopancreatography are core components of living donor liver transplant. Here, we described our 3-dimensional computed tomography- magnetic resonance cholangiopancreatography, fusion-derived computer-assisted surgical planning system to evaluate its usefulness in full graft living donor liver transplant. Materials and Methods: Among 17 consecutive full graft left living donor liver transplants, 14 were planned with the 3-dimensional computed tomography-magnetic resonance cholangiopancreatography computer-assisted surgical planning system. The system allowed us to estimate liver volume compliance, allowing for individualized graft size enlargement by means of virtual-to-real resection line modifications. Virtual graft hepatectomy obviated the need for intraoperative cholangiography in 93% of cases. Results: Graft and recipient survival rates were 82% and 77% at 1 year and 94% and 82% at 5 years, respectively. Small-for-size and high-risk small-for-size grafts constituted 44% and 31% of cases, with rate of small-for-size syndrome of 18%. We observed a 12.6 +/- 9.8% discrepancy between estimated and intraope-rative graft-weight-body-weight ratio, reflecting either volume compliance (overcalculation) or graft enlargement (undercalculation). Graft-to- remnant congestion volume index excluded 1 middle hepatic vein graft. Ninety-four percent single arterial and 100% single ductal biliary reconstructions were associated with 12% hepatic artery thrombosis and 18% biliary anastomotic leaks, respectively. Conclusions: Our 3-dimensional computed tomography- magnetic resonance cholangiopancreatography computer-assisted surgical planning system enabled (1) virtual navigation of the hilar passage with no need of intraoperative cholangiography in risky anatomy cases and (2) prevention of small-for-size syndrome in extremely small grafts by computed risk analysis.

INTRODUCTION:The robotic platform is emerging as the optimal setting for live donor hepatectomy offering precision, minimal invasiveness, better outcomes for donors, and potentially also for recipients. Nevertheless, there has not been a worldwide implementation of the technique due in part to lack of proper training and adequate access to robotic platforms. We present a single center 1,400 case experience (n = 658 right, 338 left, 404 left lateral) with step-by-step description of a standardized technique for robotic live donor hepatectomy. SURGICAL TECHNIQUE:A detailed description of the operating room setup, patient positioning, and port placement for the robotic donor hepatectomy approach is provided. The transection planes are outlined for right lobe, left lobe, and left lateral segmentectomies. Bile duct division is performed under indocyanine green (ICG) guidance using a corridor-based approach. Techniques to address anatomical variations, as well as steps for vascular clamping and graft extraction are also described. RESULTS:The standardized technique described can accommodate any anatomical variation otherwise considered for the open approach. Patients that underwent robotic donor hepatectomies experienced significant less morbidity than those with laparoscopic or open approaches. Streamlined techniques can be taught and replicated with a gradual decrease of assistance and teaching console support. CONCLUSIONS:Robotic donor hepatectomy can be safely performed in high-volume experienced centers with excellent outcomes for donors. Careful technical details must be followed to assure success of the procedure. This standardized and reproducible technique supports broader adoption of robotic donor hepatectomy, including centers aiming to establishing their robotic liver transplant programs.

OBJECTIVE:To compare the outcomes of fully robotic versus open left lobe donor hepatectomies, focusing on donor safety. BACKGROUND:Right lobe hepatectomies are traditionally preferred for adult liver transplants due to their larger graft size but may involve increased risks for donors. Left lobe hepatectomies are considered safer for donors but are less commonly used due to concerns about the small-for-size syndrome in adult settings. METHODS:We conducted an analysis of 339 living liver donors from a prospectively maintained registry at a single institution from November 2011 to June 2023, comparing 72 open and 267 robotic left lobe hepatectomies. Primary outcomes included donor complication rates until hospital discharge, whereas secondary outcomes focused on hospital stay and recipient complications. RESULTS:Robotic hepatectomy was associated with significantly less blood loss (mean 77 (SD: 68) vs 316 (SD: 168) mL, P <0.001), lower donor morbidity 6% vs 18%, P =0.003), and shorter hospital stay (3 vs 5 d, P <0.001). Adult recipients receiving robotically retrieved donor grafts were associated with a lower overall morbidity rate (40% vs 59%, P =0.033) compared to open. CONCLUSIONS:Robotic left donor hepatectomy significantly improves donor safety compared with the open approach, supporting its use as a less invasive and donor-centered option in living donor liver transplantation. This study, the largest known series of left lobe donor hepatectomies, demonstrates the robotic approach's superiority, potentially setting a new standard in the field of living donor liver transplantation.