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Background: Although advancements in desensitization protocols have led to increased ABO-incompatible (ABOi) living-donor liver transplantation (LDLT), a higher biliary complication rate remains a problem. This study evaluated the effect of baseline anti-ABO antibody titers before desensitization on biliary complications after ABOi LDLT. Methods: The study cohort comprised 116 patients in the ABO-compatible group (ABOc), 29 in the ABOi with the low titer (<1:128) group (ABOi-L), and 14 in the high titer (≥1:128) group (ABOi-H). Results: Biliary complications occurred more frequently in the ABOi-H group than in the ABOi-L and ABOc groups (7 [50.0%] vs. 8 [27.6%] and 24 [20.7%], respectively, p = 0.041). Biliary complication-free survival was significantly worse in the ABOi-H group than in the other groups (p = 0.043). Diffuse intrahepatic biliary strictures occurred more frequently in the ABOi-H group than in the other groups (p = 0.005). Multivariable analysis revealed that the high anti-ABO antibody titer (≥1:128) is an independent risk factor for biliary complications (hazard ratio 3.943 [1.635-9.506]; p = 0.002). Conclusions: A high baseline anti-ABO antibody titer (≥1:128), female sex, and hepatic artery complications are significant risk factors for biliary complications.

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Purpose: The role of paraaortic lymph node dissection (PALND) in colorectal cancer (CRC) has been less evaluated than surgical treatments for other distant metastases. We evaluated surgical outcomes after PALND and identified prognostic factors. Methods: The medical records of patients who underwent PALND for paraaortic lymph node metastasis (PALNM) were reviewed retrospectively. All patients were categorized into the M1a group (isolated PALNM, n = 27), and the M1bc group (distant metastases other than PALNM, n = 26). Three severity factors (PALNM-SF: number of harvested paraaortic lymph nodes [hLN], ≥14; number of metastatic paraaortic lymph nodes [mLN], ≥5; and lymph nodes ratio [mLN/hLN], ≥0.5) were defined to determine their effects on survival. Results: The 5-year overall survival (OS) of the M1a and M1bc groups were 61.1% and 6.4%, respectively (P = 0.0013). The 5-year disease-free survival (DFS) of the M1a group was 47.4%, and the 3-year DFS of the M1bc group was 9.1% (P < 0.001). Patients with 2 or more PALNM-SFs showed worse OS than those with 1 PALNM-SF (P = 0.017). In multivariate analysis, M1bc (non-isolated PALNM) was the only significant factor for survival. In the M1a group, patients with 2 or more PALNM-SFs showed significantly worse survival than those with a single PALNM-SF. In multivariate analysis, 2 or more PALNM-SF was a significant factor for survival. Conclusion: PALND for CRC provided favorable outcomes in the survival of an isolated PALNM, although this was uncertain for non-isolated PALNMs. The PALNM-SFs helped assess the prognosis after PALND.

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Background: Pancreatic cystic lesions (PCLs) are occasionally found in solid organ transplant (SOT) recipients. In such recipients, the risk of cancer is increased due to immunosuppressive therapy. This study investigated the prevalence of PCLs and described their clinical course in immunosuppressed patients following SOT. Methods: The presence of PCLs in a retrospective cohort of 805 consecutive SOT recipients from 2009 to 2019 was examined. The characteristics of PCLs were compared using initial and follow-up imaging, where available. These results were compared to an age- and sex-matched immunocompetent control group monitored for at least 12 months. Results: PCLs were present in 15 of 805 SOT patients (seven liver and eight kidney transplantations). The median diameter of the largest lesion was 20 mm (range, 0.2-60 mm) and 60% of lesions were benign. During follow-up imaging, the cyst size remained stable in 46.7%, increased in 13.3%, and decreased in 40.0% of the SOT group. Significantly more of the SOT patients showed PCL size reductions (P=0.007). Among SOT patients diagnosed with intraductal papillary mucinous neoplasms (6/15), worrisome features were noted in one patient at the time of cyst diagnosis. Differences in the development of worrisome features between the study and control groups were not statistically significant. Conclusions: The malignant transformation of PCLs in SOT recipients is rare and most such PCLs can be managed conservatively. The presence of a PCL should therefore not affect transplant eligibility.

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INTRODUCTION: Since its first appearance in the early 1990s, laparoscopic hepatic resection has become increasingly accepted and recognized as safe as laparotomy. The recent introduction of robotic surgery systems has brought new innovations to the field of minimally invasive surgery, such as laparoscopic surgery. The da Vinci line of surgical systems has recently released a true single-port platform called the da Vinci SP system, which has 3 fully wristed and elbowed instruments and a flexible camera in a single 2.5 cm cannula. We present the first case of robotic liver resection using the da Vinci SP system and demonstrate the technical feasibility of this platform. PATIENT CONCERNS AND DIAGNOSIS: A 63-year-old woman presented with elevated liver function test results and abdominal pain. Computed tomography (CT) and magnetic resonance cholangiopancreatography showed multiple intrahepatic duct stones in the left lateral section and distal common bile duct stones near the ampulla of Vater. INTERVENTIONS: The docking time was 8 minute. The patient underwent successful da Vinci SP with a total operation time of 135 minute. The estimated blood loss was 50.0 ml. No significant intraoperative events were observed. OUTCOMES: The numerical pain intensity score was 3/10 in the immediate postoperative period and 1/10 on postoperative day 2. The patient was discharged on postoperative day 5 after verifying that the CT scan did not show any surgical complications. CONCLUSION: We report a technique of left lateral sectionectomy, without the use of an additional port, via the da Vinci SP system. The present case suggests that minor hepatic resection is technically feasible and safe with the new da Vinci SP system in select patients. For the active application of the da Vinci SP system in hepatobiliary surgery, further device development and research are needed.

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BACKGROUNDS/AIMS: Patients with Ampulla of Vater cancer have a better prognosis than those with other periampullary cancers. This study aimed to determine the prognostic impact of lymph node metastasis on survival in patients with ampulla of Vater cancer after surgical resection. METHODS: From 1991 to 2016, we retrospectively reviewed data on 104 patients with ampulla of Vater cancer who had received pancreaticoduodenectomy. Clinicopathologic factors such as lymph node ratio (LNR) and number of metastatic lymph nodes that influence survival were statistically analyzed. RESULTS: 5-year survival rate after resection was 57.8%. Mean number of retrieved and metastatic lymph nodes was 13 and 0.95, respectively. In patients with lymph node metastasis, the median number of metastatic lymph nodes and was 1, and the mean LNR was 0.18. LNR ＞0.2 was a significant prognostic factor for overall survival. Patients with 0 or 1 metastatic lymph nodes had better survival than those with ≥2 metastatic lymph nodes. Univariate analysis revealed that histologic differentiation of tumor, lymph node metastasis, and T stage were significant prognostic factors for overall survival. Multivariate analysis revealed that tumor differentiation and number of metastatic lymph nodes were independent prognostic factors for survival. CONCLUSIONS: Pancreaticoduodenectomy is an appropriate surgical procedure with acceptable long-term survival for ampulla of Vater cancer. Patients with LNR ＞0.2 and ≥2 positive lymph node metastasis had a poor survival. Tumor differentiation and ≥2 metastatic lymph nodes were independent significant prognostic factors for overall survival. Curative resection with lymph node dissection might control lymph node spread and enhance survival outcomes.

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BACKGROUND: Resectability of liver metastasis is important to establish a treatment strategy for patients with colorectal cancer. We aimed to evaluate the effect of the distance from metastasis to the centre of the liver on surgical outcomes and survival after hepatectomy. METHODS: The clinical data of a total of 155 patients who underwent hepatectomy for colorectal cancer with liver metastasis were retrospectively reviewed. We measured the minimal length from metastasis to the bifurcation of the portal vein at the primary branch of the Glissonean tree and defined it as 'centrality'. The postoperative outcomes and survival among the patients were then analysed. RESULTS: Anatomic resections were more frequently performed, and the operative time was longer in the patients with high centrality (≤1.5 cm) than in the patients with low centrality (>1.5 cm). A size of ≥5 cm for the largest lesion, a number of lesions of ≥3 and centrality of ≤1.5 cm were found to be the independent risk factors of a positive resection margin after hepatectomy. The patients with high centrality showed worse recurrence-free survival than those with low centrality; however, there was no significant difference found in the overall survival. In the multivariate analysis, high centrality was not found to be associated with worse recurrence-free and overall survival. CONCLUSION: Centrality significantly affected the surgical outcomes and treatment strategy for liver metastasis but did not influence the survival of the patients with colorectal cancer. Active efforts through surgical resections are important to treat liver metastasis of high centrality.

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BACKGROUND: The aim of this study was to validate the safety and feasibility of pure laparoscopic extended cholecystectomy (LEC) by comparing the outcome with that of open extended cholecystectomy (OEC). Moreover, on the basis of our experience, we also aimed to investigate the learning curve of pure LEC. METHODS: This single-center study enrolled patients who were diagnosed primary gallbladder cancer with pathologically confirmed and underwent R0 resection with curative intent between January 2016 and December 2019. A total of 31 patients who underwent OEC and 17 patients who underwent LEC were selected. Propensity score matching analysis was performed in a 1:1 ratio using the nearest-neighbor matching method, and clinical information was retrospectively collected from medical records and analyzed. RESULTS: The postoperative hospital stay was statistically shorter in the LEC group (7 days) than in the OEC group (12 days). The overall surgical complication rate did not differ between the two groups. The 1- and 3-year disease-free survival rates were 82.4% and 82.4% in the OEC group and 94.2% and 71.5% in the LEC group, respectively (P = 0.94). Considering the correlation between the number of cumulative cases and the operation time and between the number of cumulative cases and the number of retrieved lymph nodes in the LEC group, as the cases were accumulated, both the operation time and the number of retrieved lymph nodes had a statistically significant correlation with the number of cases. CONCLUSIONS: LEC showed a significant advantage in terms of achieving shorter postoperative hospital stay and similar results to OEC with respect to overall complications and pathological outcomes. The present results confirm that laparoscopy can be considered a safe treatment for primary gallbladder cancer in selected patients.

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Background: Once-daily tacrolimus reduces non-compliance relative to twice-daily tacrolimus. However, little is known about the safety and efficacy of conversion from twice-daily tacrolimus to generic once-daily tacrolimus in liver transplantation (LT). Herein, we investigated the efficacy and safety of a switch from twice-daily tacrolimus to generic once-daily tacrolimus in patients with stable liver graft function. Methods: This prospective, multicenter, open-label, single-arm study was conducted in 17 medical centers for 1 year from July 2019 to July 2020 (NCT04069065). Primary endpoint was the incidence of biopsy-proven acute rejection (BPAR) for 24 weeks after conversion. Secondary endpoints were graft failure, patient death, and adverse events (AEs). Results: Of 151 screened LT patients, 144 patients were enrolled. BPAR, graft failure, and patient death did not occur in this patient population. There were no statistical differences in blood tests, liver function tests, or biochemical tests between visits in any of the patients. Median tacrolimus trough level decreased abruptly from 4.7 ng/mL to 3.2 ng/mL after generic once-daily tacrolimus conversion, but median tacrolimus dose increased due to low tacrolimus trough level. Ninety-two adverse events occurred in 54 patients. Liver enzyme levels increased in seven patients (4.9%) after the switch to generic once-daily tacrolimus, but the liver function tests of these patients normalized thereafter. There were three cases of severe AEs not related to investigational drug. Conclusions: Present study suggests that conversion from twice-daily tacrolimus to generic once-daily tacrolimus is effective and safe in stable LT patients.

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We aimed to identify clinicopathological differences and factors affecting survival outcomes of stage T2a and T2b gallbladder cancer (GBC) and validate the oncological benefits of regional lymphadenectomy and hepatic resection in these patients. This single-center study enrolled patients who were diagnosed with pathologically confirmed T2 GBC and underwent curative resection between January 1995 and December 2017. Eighty-two patients with T2a and 50 with T2b GBCs were identified, and clinical information was retrospectively collected from medical records and analyzed. Five-year overall survival rates were 96.8% and 80.7% in T2a and T2b groups, respectively (P = .007). Three- and 5-year survival rates among all patients with T2 GBC without and with lymph node metastasis were 97.2% and 94.4% and 81.3% and 81.3%, respectively (P = .029). There was no difference in survival rates between the 2 groups according to whether hepatic resection was performed (P = .320). However, in the T2b group, those who underwent hepatic resection demonstrated a better survival rate than those who did not (P = .029). The T2b group had more multiple recurrence patterns than the T2a group, and the lymph nodes were the most common site in both groups. Multivariate analysis revealed that lymph node metastasis, vascular invasion, and tumor location were significant independent prognostic factors. Hepatic resection was not always necessary in patients with peritoneal-side GBC. Considering clinicopathological features and recurrence patterns, a systematic treatment plan, including radical resection and adjuvant treatment, should be established for hepatic-side GBC.

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BACKGROUND: The aim of this study was to identify predictive factors for the recurrence of colorectal cancer liver metastasis (CRLM) and then to develop a corresponding novel scoring system that should improve the sensitivity of predicting recurrence in patients with CRLM. METHODS: A total of 295 consecutive CRLM patients were enrolled in our institution between January 2002 and December 2015. Multivariate analyses were performed to identify the variables associated with disease recurrence and established the novel scoring system based on it. RESULTS: The scoring system considered seven variables: synchronosity, CA19-9 level, number of liver metastasis, largest size of liver metastasis, resection margin of hepatic lesion, neutrophil-to-lymphocyte ratio and prognostic nutritional index. The area under the curve of ROC was 0.824 (95% confidence interval 0.767-0.882); the sensitivity of our scoring system was 87.9%, specificity was 66.7%, positive predictive value was 20.6%, and negative predictive value was 20.9%. CONCLUSION: For patients with CRLM undergoing curative hepatic resection, our novel scoring system would improve the sensitivity for prediction of disease recurrence in Case of CRLM patients.

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BACKGROUND: Single-port laparoscopic approaches are well established in the field of minimally invasive surgery; however, single-port laparoscopic distal pancreatectomy (SPLDP) has not been evaluated in a large number of distal pancreatic neoplasms. We aimed to compare single-port laparoscopic distal pancreatectomy outcomes with conventional laparoscopic distal pancreatectomy (LDP) outcomes. METHODS: We retrospectively evaluated the medical records of 101 patients who underwent SPLDP (n = 26) or LDP (n = 75). We performed 1:1 propensity score matching between the two groups. Consequently, 26 patients were included in each group. We analyzed the learning curve based on the operation time in SPLDP. RESULTS: Single-port laparoscopic distal pancreatectomy could be performed with fewer trocars (P < 0.001) and assistants (P < 0.001). However, compared to the LDP group, mean operation time was longer (278.9 vs. 178.7 min, P < 0.001) and splenic vessel preservation rates were lower (0% vs. 46.2%, P < 0.001) in the SPLDP group. The mean pain visual analogue scale score was significantly lower at postoperative day 1 (P < 0.001) and day 2 (P < 0.001) in the SPLDP group. The learning curve was determined in the 12th case for SPLDP. CONCLUSIONS: Single-port laparoscopic distal pancreatectomy is comparable in safety to conventional laparoscopic approaches for distal pancreatic neoplasms, with fewer trocars, assistants and less pain; however, operation time was longer.

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BACKGROUND: Early recurrence is associated with poor prognosis after curative resection for hepatocellular carcinoma. Thus, we studied which factors, including this inflammation-based scoring system, affect disease recurrence in single hepatocellular carcinoma patients with liver cirrhosis. METHODS: A total of 430 consecutive hepatocellular carcinoma patients were enrolled in our institution between January 2002 and December 2015. Survival rate, univariate, and multivariate analyses were performed to identify the variables associated with recurrence and early recurrence especially. RESULTS: The overall survival rate was significantly lower in the early recurrence group than in the non-early recurrence group (P<0.001). According to the multivariate analysis, protein induced by vitamin K absence or antagonist (PIVKA) greater than 200 (P=0.035), neutrophil-to-lymphocyte ratio greater than 2.0 (P<0.001), elevated Glasgow prognostic score (P=0.003), tumor size greater than 5 cm (P=0.002), and the presence of lymphovascular invasion (P=0.002) were significantly different among the groups and affected the early recurrence of hepatocellular carcinoma. The patients were categorized into five levels of risk for early recurrence according to the number of independent risk factors, and patients with no risk factors were set as the reference group. CONCLUSION: Neutrophil-to-lymphocyte ratio, Glasgow prognostic score, and serum level of PIVKA offer significant prognostic information associated with early recurrence following single lesion hepatocellular carcinoma patients with liver cirrhosis after curative resection.

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BACKGROUND: This study aimed to evaluate the clinical value of the combination of a traditional prognostic factor with a systemic inflammation-based prognostic factor in patients undergoing curative resection for pancreas head cancer diagnosed as pancreatic ductal adenocarcinoma. METHODS: From January 2005 to December 2015, 198 patients were enrolled. Various clinicopathological factors potentially associated with survival and recurrence were evaluated in this study. RESULTS: The selected cut-off values for the test prognostic factors with sufficient sensitivity and specificity were 2.8 for the neutrophil-to-lymphocyte ratio (NLR) and 70 U/mL for serum carbohydrate antigen 19-9 (CA19-9). Kaplan-Meier survival analysis demonstrated that the 5-year survival rate in patients with a high NLR and CA19-9 was 21.8% compared with 79.8% for patients with a low NLR and CA19-9. The 5-year disease-free survival rate in patients with a high NLR and CA19-9 was 0% compared with 33.9% for patients with a low NLR and CA19-9. Patients with high NLRs and high CA19-9 were more likely to have an early recurrence and multiple relapse patterns. CONCLUSION: Preoperative NLR and serum CA19-9 offer significant prognostic information for survival following curative resection of pancreas head cancer diagnosed as pancreatic ductal adenocarcinoma.

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OBJECTIVES: The aim of this study is to perform a systematic review of the clinical impact of lymph node micrometastasis in pancreatic adenocarcinoma following surgical resection. METHODS: A systematic review was conducted and published literature were searched using "pancreas or pancreatic" and "cancer or carcinoma or neoplasm", and "micrometastasis or micrometastses" in the PubMed, EMBAE, and Web of Science. RESULTS: Thirteen publications with 726 patients and 3701 lymph nodes were included in this systematic review. The detection method was immunohistochemical stains or polymerase chain reaction. The pooled proportion of patients with positive lymph node micrometastasis was 43.1% (95% Confidence interval (CI) 0.254-0.628). The pooled proportion of positive lymph node micrometastasis (number of positive lymph node micrometastasis/total number of lymph nodes examined) was 10.8% (95% CI 4.8-22.6). Among the conventional H &E negative patients, the reported 5-year survival rates of the patients without lymph node micrometastases vs. those with lymph node micrometastases in the ranged from 50% to 61% and from 0% to 36%, respectively Patients with lymph node micrometastasis showed poorer survival (Hazard ratio 4.29, 95% CI 1.27-14.41). CONCLUSIONS: The presence of lymph node micrometastasis is associated with poorer survival. Lymph node micrometastasis is applicable to stratify the risk of recurrence and the need for adjuvant therapy of post-resection patients with pancreatic adenocarcinoma in the conventional H & E lymph node negative patients.

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Patients with postpartum breast cancer have been reported to have a poor prognosis. The present study aimed to evaluate the pregnancy-related risk factors of postpartum breast cancer in Korea. We collected patient data from the Korea National Health Insurance (KNHI) Claims Database of the Health Insurance Review and Assessment Service (HIRA) for the 2009-2013 period. We evaluated the pregnancy-related risk factors for postpartum breast cancer in two population groups. For Group 1 (women who had given birth during the 2010-2012 period), data on those who were diagnosed with breast cancer from childbirth to 1-year postpartum were extracted. For Group 2, we extracted the data of women who gave birth in 2010 and traced them until December 31, 2013. In Group 1, 1,384,551 deliveries and 317 postpartum breast cancer patients were recorded in Korea between January 1, 2010, and December 31, 2012. Women aged ≥35 years (Odds Ratio [OR], 2.003; 95% Confidence Interval [CI], 1.567-2.560) and those who gave birth via cesarean delivery (OR, 1.237; 95% CI, 0.986-1.553) were considered to be at a higher risk for breast cancer. Lower risk was noted in primiparous women (OR, 0.737; 95% CI, 0.585-0.928). In Group 2, the data of 457,924 women who gave birth in 2010 were traced until December 31, 2013. Among them, 655 patients were diagnosed with breast cancer, and age ≥35 years and cesarean delivery were associated with an higher risk of breast cancer, whereas primiparous status was associated with a lower risk of breast cancer. In conclusion, older age (≥35 years) and cesarean delivery are significant risk factors for postpartum breast cancer, and primiparous women have a lower risk of developing postpartum breast cancer.

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AIM: To perform a systematic review of incidental or unsuspected gallbladder (GB) cancer diagnosed during or after cholecystectomy. METHODS: Data in PubMed, EMBASE, and Cochrane Library were reviewed and 26 publications were included in the meta-analysis. The inclusion criterion for incidental GB cancer was GB cancer diagnosed during or after cholecystectomy that was not suspected at a preoperative stage. Pooled proportions of the incidence, distribution of T stage, and revisional surgery of incidental GB cancer were analyzed. RESULTS: The final pooled population comprised 2145 patients with incidental GB cancers. Incidental GB cancers were found in 0.7% of cholecystectomies performed for benign gallbladder diseases on preoperative diagnosis (95%CI: 0.004-0.012). Nearly 50% of the incidental GB cancers were stage T2 with a pooled proportion of 47.0% (95%CI: 0.421-0.519). T1 and T3 GB cancers were found at a similar frequency, with pooled proportions of 23.0% (95%CI: 0.178-0.291) and 25.1% (95%CI: 0.195-0.317), respectively. The pooled proportion that completed revisional surgery for curative intent was 40.9% (95%CI: 0.329-0.494). The proportion of patients with unresectable disease upon revisional surgery was 23.0% (95%CI: 0.177-0.294). CONCLUSION: A large proportion of incidental GB cancers were T2 and T3 lesions. Revisional surgery for radical cholecystectomy is warranted in T2 and more advanced cancers.

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We present a method of intraoperative contrast-enhanced sonographic portography combined with indigo carmine dye injection for anatomic liver resection in hepatocellular carcinoma. During surgery, before dye infusion into the feeding portal vein, the targeted portal vein branch was directly punctured, and a microbubble contrast agent was administered under sonographic guidance. Simultaneous enhancement of the resected hepatic parenchyma with a microbubble contrast agent and blue dye improved estimation of the segmental border in the cutting plane and the tumor resection margin during liver surgery.

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Human cytomegalovirus (CMV) infection is usually self-limiting in healthy adults, but it can lead to significant complications. This report presents the case of an immunocompetent adult with fulminant hepatitis caused by a CMV infection requiring emergency living-donor liver transplantation. A 39-year-old female with persistent fever for 6 weeks was referred for fulminant hepatitis, but the underlying etiology was not identified. Rapid deterioration of consciousness led to an emergency living-donor liver transplant using a modified right lobe graft. She showed increasing CMV antigenemia after surgery and the explant liver pathology showed massive hepatic necrosis with positive staining for CMV protein. Treatment with ganciclovir improved the graft liver function and her general condition recovered. This report presents a rare case of CMV-associated fulminant hepatitis which led to emergency liver transplantation. Although CMV is rare, it should be included in the differential diagnosis of patients with severe hepatitis, even immunocompetent patients, after other more common etiologies have been excluded.

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Erythropoietic protoporphyria (EPP) is an inherited disorder of the heme metabolic pathway that is characterized by accumulation of protoporphyrin in the blood, erythrocytes, and tissues, and cutaneous manifestations of photosensitivity, all resulting from abnormalities in ferrochelatase (FECH) activity due to mutations in the FECH gene. Protoporphyrin is excreted by the liver, and excess protoporphyrin leads to cholelithiasis with obstructive episodes and chronic liver disease, finally progressing to liver cirrhosis. Patients with end-stage EPP-associated liver disease require liver transplantation. We describe here a 31-year-old male patient with EPP who experienced acute-on-chronic liver failure and underwent deceased-donor liver transplantation. Surgical and postoperative care included specific shielding from exposure to ultraviolet radiation to prevent photosensitivity-associated adverse effects. The patient recovered uneventfully and was doing well 24 months after transplantation. Future prevention and treatment of liver disease are discussed in detail.

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BACKGROUND: A majority of patients with hepatocellular carcinoma (HCC) undergoing liver transplantation (LT) meet the Milan criteria, but these are still regarded as the narrowest criteria for transplantation. Prognostic analysis of incidentally detected HCC after LT suggests that a subgroup of HCC patients is at very low risk of recurrence. To determine the criteria defining this super-selection group, we retrospectively analyzed survival data of 593 adult living-donor LT recipients with HCC in the explanted liver DISCUSSION: Tumor features of incidental HCC in 38 patients not showing recurrence were analyzed. Of these patients, 34 (89.5%) each had ≤2 tumors and tumors ≤2.0 cm in size. Applying these criteria to 555 patients with pretransplant known HCC (pkHCC) allowed us to identify 79 patients with untreated pkHCCs ≤2.0 cm in size. To date, only two of these patients have shown recurrence, making the conditions for super-selection the presence of tumors ≤2.0 cm in size, ≤2 tumors, alpha-fetoprotein ≤200 ng/mL, and no pretransplant treatment. In 87 patients satisfying these criteria, the 10-year recurrence and survival rates were 1.3% and 92.1%, respectively. After excluding patients meeting these criteria, the 5-year recurrence rates in patients satisfying the Milan, University of California at San Francisco, and Asan criteria were increased by 2.9-4.0%. In conclusion, this super-selection or super-Milan category may be used for validation assessment of various indication criteria and for the development of cost-effective post-transplantation HCC surveillance protocols. Further studies should be followed for deceased-donor LT and patients who have undergone pretransplant treatment.

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