A surgical technique using the gastroepiploic vein for portal inflow restoration in living donor liver transplantation in a patient with diffuse portomesenteric thrombosis

Portal vein thrombosis(PVT)is no longer a definitive contraindication in liver transplants(LTs)[1].Complex vascular reconstructions such as cavoportal hemitransposition(CPHT)[2–5],renoportal anastomosis(RPA)[6,7],and use of sizable collaterals(pericholedochal varix[8,9],coronary vein,peripancreatic or perigastroesophageal varices[10],right superior colic vein[11],ileocolic vein[12],and left gastric vein[13]),or combined liverpancreas-small bowel transplant[14]are required for portal inflow in patients with total portosplenomesenteric thrombosis.

Feasibility of ABO-incompatible adult living donor liver transplantation for acute-on-chronic liver failure

To the Editor:In Korea,the annual number of deceased donors for or gan transplantation per million people is still less than10.Thus,approximately 40%of patients with acute liver failure or acute-on-chronic liver failure undergo living donor liver transplantation（LDLT）.;Although the use of ABO-incompatible（ABOi）living donors is an attrac tive option,ABOi LDLT has very restricted applications

Salvage living donor liver transplantation for recurrent hepatocellular carcinoma after prior laparoscopic hepatectomy

Salvage liver transplantation(LT)is frequently performed on patients who experience recurrent hepatocellular carcinoma(HCC)after primary hepatectomy for HCC[1,2].The main concern in these patients is the technical feasibility of salvage LT,especially as prior hepatectomy may result in heavy adhesions[3,4].Salvage living donor LT(LDLT)is a more demanding procedure than salvage deceased donor LT(DDLT)using an entire donor graft with a long vascular pedicle[5,6].Because less than optimal dissection of perihepatic adhesions could result in uncontrollable pinpoint bleedings at the dissection surface[1,5],many transplant surgeons avoid performing salvage LDLT.Minimally invasive laparoscopic hepatectomy(LH)results in fewer intraperitoneal adhesions than the open method,reducing the difficulty of surgical dissection during future LT[7–10].To date,however,no study has compared salvage LDLT for recurrent HCC after LH to that after open hepatectomy(OH).

Artificial intelligence and liver transplantation:Looking for the best donor-recipient pairing

Decision-making based on artificial intelligence(AI)methodology is increasingly present in all areas of modern medicine.In recent years,models based on deep-learning have begun to be used in organ transplantation.Taking into account the huge number of factors and variables involved in donor-recipient(DR)matching,AI models may be well suited to improve organ allocation.AI-based models should provide two solutions:complement decision-making with current metrics based on logistic regression and improve their predictability.Hundreds of classifiers could be used to address this problem.However,not all of them are really useful for D-R pairing.Basically,in the decision to assign a given donor to a candidate in waiting list,a multitude of variables are handled,including donor,recipient,logistic and perioperative variables.Of these last two,some of them can be inferred indirectly from the team’s previous experience.Two groups of AI models have been used in the D-R matching:artificial neural networks(ANN)and random forest(RF).The former mimics the functional architecture of neurons,with input layers and output layers.The algorithms can be uni-or multi-objective.In general,ANNs can be used with large databases,where their generalizability is improved.However,they are models that are very sensitive to the quality of the databases and,in essence,they are black-box models in which all variables are important.Unfortunately,these models do not allow to know safely the weight of each variable.On the other hand,RF builds decision trees and works well with small cohorts.In addition,they can select top variables as with logistic regression.However,they are not useful with large databases,due to the extreme number of decision trees that they would generate,making them impractical.Both ANN and RF allow a successful donor allocation in over 80%of D-R pairing,a number much higher than that obtained with the best statistical metrics such as model for end-stage liver disease,balance of risk score,and survival outcomes following liver transplantation scores.Many barriers need to be overcome before these deeplearning-based models can be included for D-R matching.The main one of them is the resistance of the clinicians to leave their own decision to autonomous computational models.

Assessment of pathogens and risk factors associated with bloodstream infection in the year after pediatric liver transplantation

BACKGROUND Bloodstream infection(BSI)is one of the most significantly adverse events that can occur after liver transplantation(LT)in children.AIM To analyze the profile of BSI according to the postoperative periods and assess the risk factors after pediatric LT.METHODS Clinical data,collected from medical charts of children(n=378)who underwent primary LT,were retrospectively reviewed.The primary outcome considered was BSI in the first year after LT.Univariate and multivariate analyses were performed to identify risk factors for BSI and respective odds ratios(ORs).RESULTS Of the examined patients,106(28%)experienced 162 episodes of pathogen-confirmed BSI during the first year after LT.There were 1.53±0.95 episodes per children(mean±SD)among BSIcomplicated patients with a median onset of 0.4 mo post-LT.The most common pathogenic organisms identified were Coagulase-negative staphylococci,followed by Enterococcus spp.and Streptococcus spp.About half(53%)of the BSIs were of unknown origin.Multivariate analysis demonstrated that young age(≤1.3 year;OR=2.1,P=0.011),growth failure(OR=2.1,P=0.045),liver support system(OR=4.2,P=0.008),and hospital stay of>44 d(OR=2.3,P=0.002)were independently associated with BSI in the year after LT.CONCLUSION BSI was frequently observed in patients after pediatric LT,affecting survival outcomes.The profile of BSI may inform clinical treatment and management in high-risk children after LT.

Portal vein stenting as a significant risk factor for biliary stricture in adult living donor liver transplantation

BACKGROUND: Although perioperative portal vein (PV) stent implantation is an effective treatment for steno-occlusive disease in adult living donor liver transplantation (LDLT) re-cipients, we experienced high incidence of biliary anastomotic strictures (BAS) after PV stenting. In this study, we sought to clarify the relation between BAS and PV stenting and to suggest the possible mechanism of BAS and measures to reduce its in-cidence. METHODS: We retrospectively analyzed 44 LDLT recipients who underwent PV stent implantation across the line of PV anastomosis regardless of the location of steno-occlusion (stent group) and their matched controls (non-stented LDLT recipients, n=131). RESULTS: The incidence of BAS was higher in patients in the stent group than that in the control group (43.2% vs 17.6%, P=0.001). Cumulative 6-month and 1-, 2- and 5-year BAS rates were 31.8%, 34.1%, 41.4% and 43.2%, respectively, in the stent group and 13.0%, 13.8%, 16.1% and 17.8%, respectively, in the control group (P=0.001). Multivariate analysis revealed that PV stenting was an independent risk factor for BAS. CONCLUSIONS: Although PV stent implantation is a reliable treatment modality for steno-occlusive PV in adult LDLT recipients, innovative methods to prevent the PV stent from crossing the line of PV anastomosis may be necessary to reduce the incidence of postoperative BAS.

Liver transplantation during COVID-19: Adaptive measures with future significance

Following the outbreak of coronavirus disease 2019(COVID-19),a disease caused by the novel severe acute respiratory syndrome coronavirus 2(SARS-CoV-2),the field of liver transplantation,along with many other aspects of healthcare,underwent drastic changes.Despite an initial increase in waitlist mortality and a decrease in both living and deceased donor liver transplantation rates,through the implementation of a series of new measures,the transplant community was able to recover by the summer of 2020.Changes in waitlist prioritization,the gradual implementation of telehealth,and immunosuppressive regimen alte-rations amidst concerns regarding more severe disease in immunocompromised patients,were among the changes implemented in an attempt by the transplant community to adapt to the pandemic.More recently,with the advent of the Pfizer BNT162b2 vaccine,a powerful new preventative tool against in-fection,the pandemic is slowly beginning to subside.The pandemic has cert-ainly brought transplant centers around the world to their limits.Despite the unspeakable tragedy,COVID-19 constitutes a valuable lesson for health systems to be more prepared for potential future health crises and for life-saving tran-splantation not to fall behind.

Liver transplant in patients with primary sclerosing cholangitis:A retrospective cohort from Northeastern Brazil

BACKGROUND Primary sclerosing cholangitis(PSC)manifests within a broad ethnic and racial spectrum,reflecting different levels of access to health care.AIM To evaluate the clinical profile,complications and survival rates of patients with PSC undergoing liver transplantation(LTx)at a Brazilian reference center.METHODS All patients diagnosed with PSC before or after LTx were included.The medical records were reviewed for demographic and clinical variables,including outcomes and survival.The level of statistical significance was set at P<0.05.RESULTS Our cohort represented 1.6%(n=34)of the 2113 patients receiving liver grafts at our service over the past two decades.Most were male(n=19;56%).The average age(40±14 years)was similar for men and women(P=0.347).The mean follow-up time from diagnosis to LTx was 68 mo.Most patients had the classic form of PSC.Three women had PSC/autoimmune hepatitis overlap syndrome,and one patient had small-duct PSC.Alkaline phosphatase levels at diagnosis and pre-LTx model for end-stage liver disease.scores were significantly higher in males.Inflammatory bowel research(IBD)was investigated by colonoscopy in 26/34(76%)and was present in most cases(18/26;69%).IBD was less common in women than in men(44.4%vs.55.6%)(P=0.692).Cholangiocarcinoma(CCA)was diagnosed in 2/34(5.9%)patients by histopathology of the explant(survival:3 years 6 mo,and 4 years 11 mo).Two patients had complications requiring a second LTx(one after 7 d due to hepatic artery thrombosis and one after 17 d due to primary graft dysfunction).Five patients(14.7%)developed biliary stricture.The overall median post-LTx survival was 66 mo.Most deaths occurred in the first year(infection n=2,primary liver graft dysfunction n=3,unknown cause n=1).The 1-year and 5-year survival rates of this cohort were 82.3%and 70.6%,respectively,matching the mean overall survival rates of LTx patients at our center(87.1%and 69.43%,respectively)(P=0.83).CONCLUSION Survival after 1 and 5 years was similar to that of other LTx indications.The observed CCA survival rate suggests CCA may be an indication for LTx in selected cases.

Effect of smoking on the risk of gastrointestinal cancer after cholecystectomy: A national population-based cohort study

BACKGROUND The role of smoking in the incidence of colorectal cancer(CRC)or gastric cancer(GC)in populations undergoing cholecystectomy has not been investigated.AIM To evaluate the effect of smoking on CRC or GC development in cholecystectomy patients.METHODS A total of 174874 patients who underwent cholecystectomy between January 1,2010 and December 31,2017 were identified using the Korean National Health Insurance Service claims database.These patients were matched 1:1 with mem-bers of a healthy population according to age and sex.CRC or GC risk after cholecystectomy and the association between smoking and CRC or GC risk in cholecystectomy patients were evaluated using adjusted hazard ratios(HRs)and 95%CIs.RESULTS The risks of CRC(adjusted HR:1.15;95%CI:1.06-1.25;P=0.0013)and GC(adjusted HR:1.11;95%CI:1.01-1.22;P=0.0027)were significantly higher in cholecystectomy patients.In the population who underwent cholecystectomy,both CRC and GC risk were higher in those who had smoked compared to those who had never smoked.For both cancers,the risk tended to increase in the order of non-smokers,ex-smokers,and current smokers.In addition,a positive correlation was observed between the amount of smoking and the risks of both CRC and GC.CONCLUSION Careful follow-up and screening should be performed,focusing on the increased risk of gastrointestinal cancer in the cholecystectomy group,particularly considering the individual smoking habits.

Conversion from calcineurin inhibitors to mTOR inhibitors stabilizes diabetic and hypertensive nephropathy after liver transplant

AIM: To investigate if conversion to the mammalian target of rapamycin inhibitors(mTORi) improves renal function in diabetic and/or hypertensive liver transplant patients immunosuppressed with tacrolimus or cyclosporine.METHODS: The study included 86 liver graft recipients immunosuppressed with mTORi treatment after orthotopic liver transplantation(OLT), including all liver recipients with worsening renal function before conversion to mTORi(n = 55 patients) and recipients with normal renal function who converted to m TORi for other reasons(n = 31 patients). We identified patients with diabetes mellitus(n = 28), arterial hypertension(n = 27), proteinuria(n = 27) and all three factors(n = 8)(some patients have hypertension and diabetes and no proteinuria). The primary endpoint was evolution in renal function defined as the development in plasma creatinine as a function of diabetes mellitus(DM), hypertension(HT) or proteinuria. We required elevated serum creatinine for at least two weeks to define renal dysfunction.RESULTS: Only patients that converted because of renal failure with plasma creatinine levels > 1.5 mg/dL showed an improvement of renal function(2.14 to 1.77 mg/dL)(P = 0.02). Patients with DM showed no improvement of serum creatinine levels(1.31 mg/dL to 1.37 mg/dL) compared with non DM patients(1.31 mg/dL to 1.15 mg/dL)(P = 0.01), HT patients(1.48 mg/dL to 1.5 mg/dL) with non HT patients(1.21mg/d L to 1.08 mg/dL) and patients with proteinuria(1.44 mg/dL to 1.41 mg/dL) and no proteinuria(1.31 mg/dL to 1.11 mg/dL). CONCLUSION: In OLT recipients with diabetes or hypertensive nephropathy, conversion to m TORi does not improve renal function but stabilizes plasma levels of creatinine. Proteinuria is not a contraindication to conversion to m TORi; it also stabilizes renal function. Conversion to m TORi should only be avoided in patients with diabetes, hypertension and proteinuria.

Pediatric transplantation during the COVID-19 pandemic

Children infected by severe acute respiratory syndrome coronavirus 2(SARSCoV-2)seem to have a better prognosis than adults.Nevertheless,pediatric solid organ transplantation(SOT)has been significantly affected by the unprecedented coronavirus disease 2019(COVID-19)pandemic during the pre-,peri-,and posttransplant period.Undoubtedly,immunosuppression constitutes a real challenge for transplant clinicians as increased immunosuppression may prolong disease recovery,while its decrease can contribute to more severe symptoms.To date,most pediatric SOT recipients infected by SARS-CoV-2 experience mild disease with only scarce reports of life-threatening complications.As a consequence,after an initial drop during the early phase of the pandemic,pediatric SOTs are now performed with the same frequency as during the pre-pandemic period.This review summarizes the currently available evidence regarding pediatric SOT during the COVID-19 pandemic.

The ‘Unsigned highway’:An alternative route for portal vein anastomosis for non-malignant portal vein thrombosis during pediatric re-transplantation

To the Editor:Non-malignant portal vein thrombosis(PVT)remains an important issue in liver transplantation due to the technical challenges in re-establishing the portal flow to the liver graft.The prevalence of complex PVT(i.e.Yerdel grade 4)was reported to be around 2.0%[1].In the early history of liver transplantation,PVT was regarded as a contraindication.

Colonic mucormycosis presented with ischemic colitis in a liver transplant recipient

Mucormycosis is an uncommon opportunistic fungal infection with high mortality in liver transplant recipients. Mucormycosis of the gastrointestinal tract can manifest with features similar to ischemic colitis. Typically signs and symptoms of non-gangrenous ischemic colitis resolve spontaneously within 24-48 h. On the other hand, the clinical course of the mucormycosis is commonly fulminant. We encountered a case of invasive fungal colitis presenting with abdominal pain and hematochezia in a liver transplant recipient. Endoscopic examination showed multiple shallow ulcerations and edema with mucosal friabilities on the sigmoid and distal descending colon, which was consistent with ischemic colitis. However, the histological examination obtained from endoscopic biopsies showed fungal hyphae withsurrounding inflammatory cells and mucosal necrosis. The patient was successfully managed with antifungal agent without surgical treatment. Thus, early diagnosis and treatment is essential for improving the prognosis of invasive fungal infection after liver transplantation.

Liver injury associated with the use of selective androgen receptor modulators and post-cycle therapy:Two case reports and literature review

BACKGROUND Muscle growth promoters are being developed for the treatment of diseaseinduced loss of muscle mass.Ligandrol and ostarine are selective androgen receptor modulators(SARMs)with a non-steroidal structure and a presumably more favorable side effect profile.In recent years,these substances with or without“post-cycle therapy”(PCT)are often misused by amateur athletes aiming to promote muscle growth.At the same time,reports on their toxic effects on organ systems are emerging.CASE SUMMARY We report two cases of liver injury in young men who used ligandrol and/or ostarine for a few weeks followed by the use of substances for PCT.Acute liver injury occurred in both cases after stopping SARMs while on PCT.The clinical picture was dominated by jaundice and fatigue.The biochemical pattern showed a mixed type of injury with normal alkaline phosphatase and high concentrations of bilirubin and serum bile acids. Histological evidence showed predominantlycholestatic injury with canalicular bile plugs, ductopenia, and mild hepatocellulardamage without significant fibrosis. The patients recovered from the conditionafter 3 mo. The off target effects of SARMs were likely idiosyncratic, but ourreport highlights the yet unrecognized effects of other toxic substances used forPCT, supra-therapeutic doses, and the complete absence of monitoring foradverse effects.CONCLUSIONAmong muscle-building amateur athletes, SARMs (ligandrol or ostarine) and/orsubstances in PCT may cause cholestatic liver injury with prolonged recovery.

Efficacy and safety of sirolimus early conversion protocol in liver transplant patients with hepatocellular carcinoma:A single-arm, multicenter, prospective study

Mammalian target of rapamycin(m TOR) inhibitor as an attractive drug target with promising antitumor effects has been widely investigated. High quality clinical trial has been conducted in liver transplant(LT) recipients in Western countries. However, the pertinent studies in Eastern world are paucity. Therefore, we designed a clinical trial to test whether sirolimus can improve recurrence-free survival(RFS) in hepatocellular carcinoma(HCC) patients beyond the Milan criteria after LT. This is an open-labeled, single-arm, prospective, multicenter, and real-world study aiming to evaluate the clinical outcomes of early switch to sirolimus-based regimens in HCC patients after LT. Patients with a histologically proven HCC and beyond the Milan criteria will be enrolled. The initial immunosuppressant regimens are center-specifc for the frst 4-6 weeks. The following regimens integrated sirolimus into the regimens as a combination therapy with reduced calcineurin inhibitors based on the condition of patients and centers. The study is planned for 4 years in total with a 2-year enrollment period and a 2-year follow-up. We predict that sirolimus conversion regimen will provide survival benefts for patients particular in the key indicator RFS as well as better quality of life. If the trial is conducted successfully, we will have a continued monitoring over a longer follow-up time to estimate indicator of overall survival. We hope that the outcome will provide better evidence for clinical decision-making and revising treatment guidelines based on Chinese population data.

Clinical advantages of single port laparoscopic hepatectomy

AIM To evaluate the clinical advantages of single-port laparoscopic hepatectomy(SPLH) compare to multiport laparoscopic hepatectomy(MPLH).METHODS We retrospectively reviewed the medical records of 246 patients who underwent laparoscopic liver resection between January 2008 and December 2015 at our hospital. We divided the surgical technique into two groups; SPLH and MPLH. We performed laparoscopic liver resection for both benign and malignant disease. Major hepatectomy such as right and left hepatectomy was also done with sufficient disease-free margin. The operative time, the volume of blood loss, transfusion rate, and the conversion rate to MPLH or open surgery was evaluated. The post-operative parameters included the meal start date after operation, the number of postoperative days spent in the hospital, and surgical complications was also evaluated.RESULTS Of the 246 patients, 155 patients underwent SPLH and 91 patients underwent MPLH. Conversion rate was 22.6% in SPLH and 19.8% in MPLH(P = 0.358). We performed major hepatectomy, which was defined as resection of more than 2 sections, in 13.5% of patients in the SPLH group and in 13.3% of patients in the MPLH group(P = 0.962). Mean operative timewas 136.9 ± 89.2 min in the SPLH group and 231.2 ± 149.7 min in the MPLH group(P < 0.001). The amount of blood loss was 385.1 ± 409.3 m L in the SPLH group and 559.9 ± 624.9 m L in the MPLH group(P = 0.016). The safety resection margin did not show a significant difference(0.84 ± 0.84 cm in SPLH vs 1.04 ± 1.22 cm in MPLH, P = 0.704). Enteral feeding was started earlier in the SPLH group(1.06 ± 0.27 d after operation) than in the MPLH group(1.63 ± 1.27 d)(P < 0.001). The mean hospital stay after operation was non-significantly shorter in the SPLH group than in the MPLH group(7.82 ± 2.79 d vs 7.97 ± 3.69 d, P = 0.744). The complication rate was not significantly different(P = 0.397) and there was no major perioperative complication or mortality case in both groups. CONCLUSION Single-port laparoscopic liver surgery seems to be a feasible approach for various kinds of liver diseases.

Acute pancreatitis induced by transarterial chemoembolization:a single-center experience of over 1500 cases

BACKGROUND： Acute pancreatitis is a relatively rare but po- tentially lethal complication after transarterial chemotherapy. This study aimed to review the complications such as acute pancreatitis after transarterial chemotherapy with or without embolization for hepatocellular carcinoma. METHODS： A total of 1632 patients with hepatocellular car- cinoma who had undergone transarterial chemoembolization from ]anuary 2000 to February 2014 in a single-center were reviewed retrospectively. We investigated the potential com- plications of transarterial chemoembolization, such as acute pancreatitis and acute pancreatitis-related complications. RESULTS： Of the 1632 patients with hepatocellular carcinoma who had undergone 5434 transarterial chemoembolizations, 1328 were male and 304 female. The median age of these pa- tients was 61 years. Most （79.6%） of the patients suffered from HBV-related hepatoceUular carcinoma. The median tumor size was 5.2 cm. Of the 1632 patients, 145 patients underwent transarterial chemoembolization with doxorubicin elut- ing bead, making up a total of 538 episodes. The remaining patients underwent transarterial chemoembolization with cisplatin. Seven （0.4%） patients suffered from acute pancre- atitis post-chemoembolization. Six patients had chemoembo- lization with doxorubicin and one had chemoembolization with cisplatin. Patients who received doxornbicin eluting bead had a higher risk of acute pancreatitis [6/145 （4.1%） vs 1/1487 （0.1%）, P〈0.0001]. Two patients had anatomical arterial variations. Four patients developed acute pancreatitis- related complications including necrotizing pancreatitis （n=3） and pseudocyst formation （n=1）. All of the 4 patients resolved after the use of antibiotics and other conservative treatment. Three patients had further transarterial chemoembolization without any complication. CONCLUSIONS： Acute pancreatitis after transarterial chemo- embolization could result in serious complications, especially after treatment with doxorubicin eluting bead. Continuation of current treatment with transarterial chemoembolization after acute pancreatitis is feasible providing the initial attack is completely resolved.

Sequential transcatheter arterial chemoembolization and portal vein embolization before right hemihepatectomy in patients with hepatocellular carcinoma

Background:Recent studies showed that sequential selective transcatheter arterial chemoembolization(TACE)and portal vein embolization(PVE)provided better future liver remnant(FLR)regeneration rate and disease-free survival following surgery compared with PVE alone.The present study aimed to clarify whether preoperative sequential TACE and PVE before right hemihepatectomy can reduce postoperative hepatocellular carcinoma(HCC)recurrence and improve long-term disease-free and overall survival.Methods:Recurrence and survival outcomes were retrospectively evaluated in 205 patients with HCC who underwent right hemihepatectomy by a single surgeon from November 1993 to November 2017.Patients were divided into four groups according to the procedure performed before the surgery:sequential TACE and PVE(TACE-PVE),PVE-only,TACE-only,or na?ve control groups.The baseline patient and tumor characteristics,postoperative outcomes,recurrence-free survival and overall survival were analyzed.Results:Baseline patient and tumor characteristics upon diagnosis were similar in all four groups,while sequential TACE and PVE were well tolerated.The TACE-PVE group had a higher mean increase in percentage FLR volume compared with that of the PVE-only group(17.46%±6.63%vs.12.14%±5.93%;P=0.001).The TACE-PVE group had significantly better overall and disease-free survival rates compared with the other groups(both P<0.001).Conclusions:Sequential TACE and PVE prior to surgery can be an effective therapeutic strategy for patients with HCC scheduled for major hepatic resection.The active application of preoperative sequential TACE and PVE for HCC would allow more patients with marginal FLR volume to become candidates for major hepatic resection by promoting compensatory FLR hypertrophy without the deterioration of basal hepatic functional reserve or tumor progression.

Little girl who conquered the "ALPPS''

An insufficient future liver remnant(FLR)is associated with post-hepatectomy liver failure.Associating liver partition and portal vein ligation for stage hepatectomy(ALPPS)has been shown to be effective for the induction of rapid FLR hypertrophy so as to improve the resectability in patients with insufficient FLR.We hereby report our experience of this novel approach for a 6-year-old patient with hepatoblastoma.Computed tomography showed a hepatoblastoma measuring12.5 cm×9.9 cm×11.7 cm in the right liver(Couinaud segmentⅣ,ⅤandⅧ).Volumetric assessment of the FLR i.e.,left lateral section was 112.6 mL i.e.,21.2%of the estimated total liver volume.In view of the small-for-size FLR,ALPPS was contemplated.An anterior approach was adopted for the in-situ parenchymal split without mobilisation of the right liver.FLR volumetry on the seventh postoperative day was 160.7 mL,which represented a 46.1%gain in volume,and a FLR/ESLV ratio of 30.2%.A right trisectionectomy was performed on the eighth postoperative day.Postoperative recovery was uneventful.Patient was discharged on day 16 after the first operation.To our knowledge,this was the first report that showed the applicability of ALPPS to a paediatric patient.

Biliary phytobezoar resulting in intestinal obstruction

Phytobezoar is the most common type of bezoar.It is composed of indigestible vegetable matter and is usually found in the stomach.Biliary phytobezoar is extremely rare and difficult to diagnose preoperatively.The pathogenesis is not clear,and there have been only a few reports of biliary bezoars associated with sphincteric impairmentat the ampulla of Vater.Here,we present a report of biliary bezoar that resulted in jejunal obstruction.We were unable to identifythe bezoar in the extrahepatic bile duct until it obstructed the small bowel lumen.To our knowledge,this is the first report of small bowel obstruction resulting frommigration of a biliary bezoar.