Akihiko Soyama

Perioperative synbiotic treatment to prevent infectious complications in patients after elective living donor liver transplantation: a prospective randomized study

BACKGROUND Although the effect of synbiotic therapy using prebiotics and probiotics has been reported in hepatobiliary surgery, there are no reports of the effect on elective living-donor liver transplantation (LDLT). METHODS Fifty adult patients undergoing LDLT between September 2005 and June 2009 were randomized into a group receiving 2 days of preoperative and 2 weeks of postoperative synbiotic therapy (Bifidobacterium breve, Lactobacillus casei, and galactooligosaccharides [the BLO group]) and a group without synbiotic therapy (the control group). Postoperative infectious complications were recorded as well as fecal microflora before and after LDLT in each group. RESULTS Only 1 systemic infection occurred in the BLO group (4%), whereas the control group showed 6 infectious complications (24%), with 3 cases of sepsis and 3 urinary tract infections with Enterococcus spp (P = .033 vs BLO group). No other type of complication showed any difference between the groups. CONCLUSIONS Infectious complications after elective LDLT significantly decreased with the perioperative administration of synbiotic therapy.

Intraoperative portal venous pressure and long‐term outcome after curative resection for hepatocellular carcinoma

Outcomes of liver resection for hepatocellular carcinoma (HCC) have improved owing to better surgical techniques and patient selection. Portal hypertension may influence outcome but the preoperative definition and role of portal hypertension are far from clear. The aim of this study was to elucidate the influence of portal venous pressure (PVP) measured directly during surgery on outcomes of liver resection in patients with HCC.

Standardized less invasive living donor hemihepatectomy using the hybrid method through a short upper midline incision.

BACKGROUND Recently, applications of less invasive liver surgery in living donor hepatectomy (LDH) have been reported. The objective of this study was to evaluate the safety and efficacy of a hybrid method with a midline incision for LDH. METHODS Hemihepatectomy using the hybrid method was performed in the fifteen most recent among 150 living donors who underwent surgery between 1997 and August 2011. Six donors underwent right hemihepatectomy and 9 underwent left hemihepatectomy. An 8-cm subxiphoid midline incision was created for hand assistance during liver mobilization and graft extraction. After sufficient mobilization of the liver, the hand-assist/extraction incision was extended to 12 cm for the right hemihepatectomy and 10 cm for a left hemihepatectomy. Encircling the hepatic veins and hilar dissection were performed under direct vision. Parenchymal transection was performed with the liver hanging maneuver. Bile duct division was performed after visualizing the planned transection point by encircling the bile duct using a radiopaque marker filament under real-time C-arm cholangiography. RESULTS All procedures were completed without any extra subcostal incision. All grafts were safely extracted through the 10-12-cm upper midline incision without mechanical injury. No donors required an allogeneic transfusion; all of them have returned to their preoperative activity levels. CONCLUSION LDH by the hybrid method with a short upper midline incision is a safe procedure.

Elective living donor liver transplantation by hybrid hand-assisted laparoscopic surgery and short upper midline laparotomy

BACKGROUND Although the technique of liver transplantation is well developed, the invasiveness of the operation can be decreased with laparoscopic procedures. METHODS We performed elective living donor liver transplantation (LDLT) through a short midline incision combined with hand-assisted laparoscopic surgery (HALS). Nine selected patients with end stage liver disease underwent the procedure between July, 2010 and February, 2011 (median age 60, median Child-Pugh 9, median MELD score 14). Splenectomy was performed simultaneously in 7 cases. The liver (and spleen) were mobilized by a sealing device under a HALS procedure with an 8-cm upper midline incision, followed by explantation of the diseased liver (and spleen) through the upper midline incision which was extended to 12 to 15 cm. Partial liver grafts were implanted through the upper midline incision. RESULTS The median duration of the operation was 741 minutes, the median time needed for anastomosis was 48 minutes, the median blood loss was 3,940 g, and the median liver weight was 866 g. Eight recipients are alive and have good graft function. A difficult implantation for one patient required an additional right transverse incision. When compared with 13 recent liver recipients who underwent LDLT with a regular Mercedes-Benz-type incision, no clinically relevant drawbacks of the HALS hybrid procedure were observed. CONCLUSION We have shown the feasibility and safety of LDLT performed through a short midline incision without abdominal muscle disruption with the aid of HALS.

Two-surgeon technique using saline-linked electric cautery and ultrasonic surgical aspirator in living donor hepatectomy: its safety and efficacy

BACKGROUND Saline-linked electric cautery (SLC) is introduced as an effective device to reduce blood loss in liver surgery. The aim of the current study was to evaluate the safety and efficacy of a 2-surgeon technique using SLC and the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab, Boulder, CO) in living donor hepatectomy. METHODS Forty-three living donor right hepatectomy cases were enrolled in this study. The first 28 cases underwent liver transection with CUSA alone (CUSA group), while additional SLC was applied in the current 15 cases (2-surgeon technique, TS group). RESULTS Blood loss was significantly reduced by the 2-surgeon technique (1,115.2 +/- 652.9 g in CUSA group vs 732.3 +/- 363.6 g in TS group, P < .05). In the TS group, there was no bile leakage from the cut surface. The early graft function and postoperative recipient survival were not significantly different between the groups. CONCLUSIONS According to our single-center experience, blood loss and donor complications in living donor hepatectomies were significantly reduced using a 2-surgeon technique using CUSA and SLC, while maintaining the graft viability.

The current status and future perspectives of organ donation in Japan: learning from the systems in other countries

The revised Organ Transplant Law came into effect in Japan in July 2010. The law allows for organ procurement from brain-dead individuals, including children, with family consent from subjects who had not previously rejected organ donation. Nevertheless, the number of cadaveric organ donations has not increased as expected. The Spanish Model is widely known as the most successful system in the field of organ donation. The system includes an earlier referral of possible donors to the transplant coordination teams, a new family-based approach and care methods, and the development of additional training courses aimed at specific groups of professionals, which are supported by their corresponding societies. South Korea, a country which neighbors Japan, has recently succeeded in increasing the rates of organ donation by introducing several systems, such as incentive programs, an organ procurement organization, a donor registry, and a system to facilitate potential donor referral. In this review, we present the current status of organ donation in Japan and also explore various factors that may help to improve the country’s low donation rate based on the experiences of other developed countries.

The usefulness of a high-speed 3D-image analysis system in pediatric living donor liver transplantation

BACKGROUND Since March 2010, we have used a high-speed 3D-image analysis system (SYNAPSE VINCENT) to calculate the graft volume in living donor liver transplantation (LDLT) to replace CT volumetry. The SYNAPSE VINCENT is capable of extracting each vessel territory in the liver and displaying 3D images simply, quickly, and accurately. Therefore, we report here the usefulness of the SYNAPSE VINCENT in pediatric LDLTs in overcoming issues with perfusion area of hepatic venous tributaries in monosegmental grafts. MATERIAL/METHODS The SYNAPSE VINCENT was used in three pediatric patients. In two of these cases, the possibility of monosegmental grafts was assessed when calculating graft volumetry of segment III. RESULTS The graft recipient weight ratio (GRWR) with graft volumetry measurements of the left lateral segment were 1.8-5.6%. GRWR of segment III were 2.3 and 2.0%. Since donor V2, venous branch to segment II and V3, venous branch to segment III were independently branching in one case, the monosegmental graft could be evaluated preoperatively according to the venous perfusion. CONCLUSIONS Graft volumetry using the SYNAPSE VINCENT was useful for planning the LDLT operative procedures, especially in infants possibly in need of monosegmental graft.

Human T-cell leukemia virus type I–associated myelopathy following living-donor liver transplantation

This report describes a patient who developed human T‐cell leukemia virus type I–associated myelopathy (HAM) following a living‐donor liver transplantation (LDLT) for liver cirrhosis due to hepatitis C virus (HCV) infection. Both the recipient and the living donor (his sister) were human T‐cell leukemia virus type I (HTLV‐I) carriers. Since the LDLT, he had been treated with immunosuppressive drugs such as tacrolimus and steroids as well as interferon‐α to prevent rejection and a recurrence of the HCV infection, respectively. Even though the HTLV‐I proviral load had decreased upon interferon treatment, he developed a slowly progressive gait disturbance with urinary disturbance 2 years after the LDLT and was diagnosed with HAM. This appears to be the first report of HAM development in an HLTV‐I–infected LDLT recipient. Liver Transpl 14:647–650, 2008.

A secured technique for bile duct division during living donor right hepatectomy

Accordingly, we should cutthe bile duct as close as possible to the commonhepatic duct, but biliary stricture in the remnant liverof the donor is a great concern. To overcome theseproblems, we describe our technical inventions forsafe and accurate bile duct division during living do-nor right hepatectomy.During hilar dissection, the right hepatic artery andright portal vein are fully exposed and isolated fromthe hilar plate. At the final step of subsequent paren-chymal transection, the right hilar plate is fully ex-posed and encircled with radiopaque marker fila-ment, which is obtained from surgical gauze (Fig. 1).Intraoperative cholangiography is then performed viaa catheter placed in the cystic duct (Fig. 2A). C-armfluoroscopy is adapted during this procedure to en-able us to check the optimal cutting point of the bileduct, which is made clear by pulling the filament andadjusting the accurate angle (Fig. 2B). The right hilarplate including the right hepatic duct is then sharplydivided with scissors, and the stump of the remnantbile duct is closed with continuous 6-0 absorbablemonofilament sutures ([Polydioxanone] Suture II,Ethicon, Somerville, NJ). Cholangiography with C-arm fluoroscopy is performed again to check the bil-iary leakage or stricture in the remnant bile duct (Fig.2C). The right liver graft is then removed after theright hepatic artery, portal vein, and hepatic veinhave been divided (Fig. 2D).Of 54 living donor hepatectomies from August 1997to December 2005, 38 underwent right hepatectomy,and the present procedure was adapted for use in thelast 10 cases. Compared to the first 28 cases withordinary cholangiography, the incidence of multipleducts in the graft was significantly reduced (3/10 vs.20/28, respectively;

Living donor liver transplantation with extensive caval thrombectomy for acute-on-chronic Budd-Chiari syndrome

The key consideration when performing living donor liver transplantation (LDLT) in patients with Budd-Chiari syndrome (BCS) is careful management of a stenotic or occluded inferior vena cava (IVC), because it is not possible to replace the recipient stenotic or occluded IVC with donor IVC as in cadaver donor transplantation. We describe how we performed LDLT with extensive thrombectomy in a patient with acuteon-chronic BCS with a totally thrombosed retrohepatic IVC. The operation was successful and the patient remains well, with follow-up images showing a patent IVC and hepatic veins. To our knowledge, LDLT for a BCS patient with severe extensive caval thrombus has never been reported before. We consider that the successful outcome of this patient clearly demonstrates the feasibility of our technique of extensive thrombectomy, without a vessel graft, to manage a stenotic or occluded IVC in LDLT in patients with BCS.