Background Sometimes, it seems to be difficult to preserve the aberrant hepatic artery (HA) during pancreaticoduodenectomy (PD), with respect to en bloc lymph node dissection, especially in the case of aberrant right hepatic artery (RHA). Therefore, we evaluated the influence of incomplete en bloc lymph node (LN) dissection when aberrant RHA arises. Methods We reviewed 103 patients with mid-to-distal common bile duct (CBD) cancers who underwent PD by one surgeon at Asan Medical Center from December 1994 to November 2005 (73 men, 30 women; mean age, 61.1 ± 9.4 (range: 40-84) years). The mean follow-up period was 32.7 months. We compared the normal RHA group with the aberrant RHA group. Results Eighty-eight cases showed normal RHA anatomy, including nine cases (8.7%) of aberrant left hepatic artery (LHA) with normal RHA cases (normal HA group). RHA anomalies were observed in 15 cases (14.6%, aberrant HA group). In all cases, there was no direct invasion of cancer to aberrant HA. Among two groups, 43 cases (41.7%) showed recurrence and there was no significant difference in recurrence between two groups (p = 0.202). Three-year and 5-year overall survivals were 33.3% and 28.5% in the normal HA group, whereas 47.1% and 28.3% in the aberrant RHA group, respectively. There also was no statistically significant difference in survival (p = 0.763). Conclusions When performing PD for CBD cancer, aberrant RHA should be preserved if there was no cancerous invasion and it does not seem to affect the recurrence of disease and overall survival of patients.

Continuous venovenous hemodiafiltration (CVVHDF) was used to eliminate pentobarbital from the blood of a 30-year-old potentially brain dead male patient with traumatic intracranial hemorrhage after a motorcycle accident. The Acute Physiology and Chronic Health Evaluation (APACHE) II score of hospital day 1 was 24, but by day 8 it was 36, when the patient was considered to be brain dead. To control seizures and reduce intracranial pressure, pentobarbital had been administered in a continuous flow (2,880 mg/day for 5 days). Coma can be induced by pentobarbital at a serum level of 1∼5 mg/dL. However, drug intoxication should be excluded from a brain death evaluation; therefore, the patient was not given any drug for approximately 88 hrs after ceasing pentobarbital in order for serum level to dip below 0.5 mg/dL (which is the hypnotic level). At 48 hours from CVVHDF, the pentobarbital level was close to the hypnotic level (0.1∼0.5 mg/dL). Before stopping, the serum level of pentobarbital was 3.89 mg/dL and between 48 and 72 hours from CVVHDF, 4 cycles of pentobarbital half-life elimination (0.24 mg/dL) could be measured. Therefore, we suggest that in case of potential brain dead patients who have been administered pentobarbital, CVVHDF can enhance the elimination of pentobarbital from the circulatory system and shorten the waiting time for a brain death evaluation.

Background: We would like to report the first case of successful organ donation after withdrawal of life-sustaining treatment (WLST) in Korea. Methods: A 52-year-old male patient who had cerebral hemorrhage was the potential brain-dead donor. After passing the first brain death examination, according to the recommendation of a neurologist, electroencephalograms (EEG) were performed 5 times at intervals of 2 to 3 days and they did not show flat EEGs. Since the family members' willingness to donate organs was very strong, they agreed to donation after circulatory death (DCD) after WLST in the operating room (OR) without them. The patient was transferred to the OR at 7:30 PM on July 3, 2020. Surgical drape was done for the donor. At 8:00 PM, an intensivist in charge of the patient performed extubation and stopping the vasopressors at the same time. In 1 minute, oxygen saturation (SpO 2) fell below 70%, which meant functional warm ischemia time began. At 8:15 PM, asystole was confirmed, and after a 5-minute "no touch time", declaration of circulatory death was done by the intensivist at 8:20 PM. Afterwards, all recipient surgeons who were waiting with surgical gown at the next OR moved to the donor's OR and performed organ procurement surgery. Results: Aortic clamp and HTK fluid perfusion started at 8:22 PM, 2 minutes after the incision started. Liver was out at 8:56 PM and kidney was out at 9:11 PM. Organs quality were good and they were donated well to the recipients. Conclusions: Since this case started with donation after brain-death, it is strictly categorized as DCD IV. In DCD IV, if the life-sustaining treatment is stopped due to unsuccessful brain death determination, it becomes DCD III process. All potential recipients were already arranged through KONOS. We can actively perform DCD after WLST in Korea with the setup of laws and systems for DCD.

Summary There might be discordance between inter‐lobar borders of the main portal fissure (MPF) using the middle hepatic vein (MHV) and of the portal segmentation. Forty‐five living donors who underwent right hepatectomy for the adult recipients from 2007 to 2011 in a tertiary hospital were retrospectively analyzed. The donors were classified into conventional right hepatectomy along the MPF (cRL group, n = 26) and modified right hepatectomy along right‐side shifted transection plane from the MPF (mRL group, n = 19). The cRL donors had higher postoperative peak level of INR (1.84 vs. 1.62; P = 0.022), and bilirubin (3.37 mg/dl vs. 2.74 mg/dl; P = 0.065) than the mRL donors. cRL donors experienced greater depression of platelet count (144 per nL vs. 168 per nL; P = 0.042) and enlargement of splenic volume (52% vs. 37%; P = 0.025) than mRL donors for 7 days after hepatectomy. The regeneration of the left lateral sector was more accelerated in the cRL donors than the mRL donors for postoperative 3 months (148% vs. 84%; P = 0.015). There were no differences in the post‐transplant graft function, incidence of complications, and graft survival rates between the two groups of recipients (P > 0.05). This study suggests that the conventional right hepatectomy along the MHV might increase donor risk by reducing parenchymal liver volume of the segment IV.