D. Fukushima

Hepatic venous reconstruction using the superficial femoral vein in a right‐lobe living donor liver transplant patient with interrupted inferior vena cava

Anatomical abnormalities in patients with BA often include polysplenia, preduodenal portal vein, interrupted retrohepatic IVC, cardiac abnormalities, and situs inversus. In LDLT patients who had congenital vascular anomalies, additional surgical modifications for the reconstruction of hepatic venous branches are sometimes necessary to prevent venous parenchymal congestion. We report a 12‐yr‐old female with post‐Kasai BA with interrupted retrohepatic IVC who underwent right‐lobe LDLT because the left liver graft volume was insufficient. The donor right liver graft had three major hepatic branches, including the RHV, IRHV, and MHV tributary (V8). We performed hepatic venous reconstruction by creating a large, wide triple orifice consisting of the RHV and two SFVs, which were anastomosed to the V8 and IRHV using the donors SFV as an interposition graft. In conclusion, the reconstruction of venous orifices for right‐lobe LDLT patients with the absent retrohepatic IVC is can be carried out using an SFV graft derived from the living donor or the recipient.

Rituximab therapy and reduction of immunosuppression to rescue graft function after renal posttransplantation lymphoproliferative disorder found by macrohematuria in a pancreas and kidney transplant recipient: a case report.

INTRODUCTION Posttransplantation lymphoproliferative disorder (PTLD) remains an uncommon complication of solid organ transplantation, with a high mortality rate reported after conventional therapies. Epstein-Barr virus (EBV) may cause PTLD, but most EBV infections after transplantation are clinically silent reactivations, so the detection of PTLD is often delayed. Recently we experienced the rare case of intrarenal graft PTLD found by macrohematuria in a simultaneous pancreas and kidney transplant recipient. The grafts were saved by treatments with rituximab, cyclophosphamide, hydroxydaunorubicin, and prednisone-based chemotherapy (R-CHOP) after reduction of immunosuppression (IR). METHODS This 37-year-old man with insulin-dependent diabetes underwent simultaneous pancreas and kidney transplantation (SPK) with enteric drainage. Six months after transplantation, he displayed macrohematuria, which we investigated by blood tests, computer tomography (CT) scan, positron emission tomography (PET)-CT, and magnetic resonance imaging, recognizing a tumor in the transplanted renal graft. An open biopsy showed a CD20-positive PTLD. We started treatments with IR, rituximab (375 mg/m(2), weekly for 2 cycles) and R-CHOP therapy: rituximab (375 mg/m(2)) plus CHOP every 3 weeks for 6 cycles. RESULTS IR and R-CHOP therapy achieved a complete remission (CR). CR has continued for 14 months at the time of writing. The maximum level of EBV DNA was 259 copies/μg DNA, but 2 months after these therapies, the level had decreased to normal. The patient had no impairment of pancreas and kidney graft functions. CONCLUSIONS The outcome of intragraft PTLD in the kidney of an SPK recipient suggested that the negative impact of IR on graft function may be compensated by the immunosuppressive effects of rituximab, allowing reduced immunosuppression during chemotherapy.

Unique histopathological features of graft biopsies with liver function abnormalities in living donor liver transplant patients receiving basiliximab induction therapy

Sato K, Sekiguchi S, Kawagishi N, Akamatsu Y, Ishida K, Fukushima D, Miyagi S, Takeda I, Yamaguchi M, Oguma S, Fujimori K, Sato A, Satomi S. Unique histopathological features of graft biopsies with liver function abnormalities in living donor liver transplant patients receiving basiliximab induction therapy.
Clin Transplant 2011: 25: 61–68.

Epstein-Barr virus--associated posttransplantation lymphoproliferative disorder with tacrolimus metabolism deterioration in infants after living-donor liver transplantation.

Background Posttransplantation lymphoproliferative disorder (PTLD) in infants after liver transplantation is strongly associated with tacrolimus (Tac) administration and primary Epstein-Barr virus (EBV) transmission. Methods From 1991 to 2012, 32 survivors younger than 2 years who had undergone living-donor liver transplantation using Tac for primary immunosuppression were retrospectively investigated for changes in Tac trough levels before and at the onset of posttransplantation viral infection episodes. Results Twenty-one recipients experienced 33 viral infection episodes associated with EBV-related PTLD (n=5), symptomatic EBV infection without development of PTLD (n=8), and other viral infections (n=20). Although the average Tac trough levels during the 2 months before the onset of viral infection episodes were similar among the 33 episodes (9.0±2.8 ng/mL), the Tac trough levels at the onset were significantly higher in the episodes with PTLD than in those with EBV infection without the development of PTLD and with other viral infections (19.2±9.0 ng/mL vs. 9.3±5.2 ng/mL and 10.6±5.1 ng/mL, respectively) (P<0.05). Tacrolimus trough levels at the onset of PTLD were significantly higher during the 2 months before the onset (median, 1.83 times higher than average) compared with EBV infection (1.14 times higher) and other viral infections (1.06 times higher) (P<0.05). The Tac blood concentration-to-dose ratio at the onset of PTLD was more than twice as high as the average value during the 2 months before the onset. Conclusion Deteriorated Tac metabolism accompanied by a positive change in the blood EBV DNA load may enable us to predict the development of PTLD in liver-transplanted infants with viral infection.

Early post‐transplant hyperbilirubinemia is a possible predictive factor for developing neurological complications in pediatric living donor liver transplant patients receiving tacrolimus

The cause of post‐transplant CNI‐NCs is multifactorial and not ascribed solely to CNI toxicity. A total of 90 children (aged <20 years) who underwent LDLT were evaluated to investigate the predictive factors associated with CNI‐NCs. Twelve patients (13.3%) developed CNI‐NCs after LDLT (age range, 2‐15 years). The symptoms of CNI‐NCs were seizures, VD, and stupor. The median onset of CNI‐NCs was 10 days (range, 5‐30 days) post‐transplant. In the univariate analysis, higher recipient age at LDLT, donor age and recipients BW, lower actual GV/SLV and TAC dosage/BW, and higher mean T‐Bil and sodium level for 7 days after transplantation were independently significantly associated with TAC‐NCs. Multivariate analysis showed that the T‐Bil level in the first week after LDLT was the only significant independent predictive factor for TAC‐NCs (HR, 1.588; 95% CI, 1.042‐2.358; P=.031). In conclusion, CNI‐NCs occurred most frequently in children over 5 years and were associated with hyperbilirubinemia for 7 days post‐transplant, regardless of TAC levels. The transplant team should refer to a neurologist to define the diagnosis and to collaborate to resolve the neurological problems.

Solitary hepatic granuloma preoperatively diagnosed as intrahepatic cholangiocellular carcinoma: report of a case

We herein report the case of a 67-year-old female with a solitary hepatic granuloma preoperatively diagnosed as a mass-forming type of intrahepatic cholangiocellular carcinoma. Magnetic resonance imaging using gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid as a contrast medium is expected to be useful for making a differential diagnosis between hepatic granuloma and other hypovascular liver tumors, such as the mass-forming type of intrahepatic cholangiocellular carcinoma and metastatic liver tumors.

Contralateral glissonian pedicle occlusion in a case of portal vein tumor thrombosis.

To dissect portal vein branches directly and encircle them separately is a common procedure that is performed to control back flow bleeding during operations for hepatocellular carcinoma with portal vein tumor thrombosis. However, this technique has an increased risk of injuring contralateral portal branches and disseminating thrombosis fragments to the remnant liver. We present an alternative technique using right-sided glissonian pedicle occlusion for hepatocellular carcinoma with left portal vein tumor thrombosis due to complex anatomical vasculatures of the hepatic pedicle. This technique would be very useful for liver resection of hepatocellular carcinoma with the major type of portal vein tumor thrombosis.

CLINICAL FEATURES OF CALCINEURIN-INHIBITOR ASSOCIATED NEUROLOGICAL COMPLICATIONS IN PEDIATRIC LIVING DONOR LIVER TRANSPLANTATION: 1073

Y. Kobayashi1, K. Sato2, S. Sekiguchi3, N. Kawagishi3, Y. Akamatsu2, S. Miyagi1, I. Takeda4, D. Fukushima1, C. Nakanishi5, K. Fujimori6, S. Satomi7 1Advanced Surgical Science And Technology Division, Department Of Surgery, Tohoku University Hospital, Sendai/JAPAN, 2Advanced Surgical Science And Technology Division, Department Of Surgery, Tohoku University hospital, Sendai/JAPAN, 3Advanced Surgical Science And Technology Division, Department Of Surgery, Tohoku Univarsity hospital, Sendai/JAPAN, 4Transplantation, Reconstruction And Endoscopic Surgery, Tohoku University, Sendai/JAPAN, 5Advanced Surgical Science And Technology Division, Department Of Surgery, Tohoku University hospital, sendai/JAPAN, 6, Tohoku University, Sendai/JAPAN, 7Division Of Advanced Surgical Science And Technology, Tohoku University, Sendai/JAPAN