H Kawarasaki

Small-for-size grafts in living-related liver transplantation

BACKGROUNDnThe problems associated with small-for-size grafts in living-related liver transplantation are not fully understood.nnnSTUDY DESIGNnA consecutive series of 79 patients underwent 80 living-related liver transplantation procedures, including one retransplant, at the University of Tokyo from January 1996 to January 2000. They were divided into two groups by graft size: graft weight/recipient standard liver volume ratios of 40% or less (n = 24), and more than 40% (n = 56). Preoperative status, mortality, morbidity, duration of hospital stay, and postoperative graft function were examined and compared between the groups.nnnRESULTSnThe rate of patients who were restricted to the intensive care unit preoperatively was comparable between the groups (33% versus 21%, p = 0.27). The mean standard liver volume ratios were 37% in the small graft group and 84% in the large group. Survival rates were 80% (5 of 24) for the small graft group, which was significantly lower than that for the large group (96%, 54 of 56, p = 0.02). The rate of acute rejection was comparable between the groups (33% versus 43%, p = 0.47). Vascular complication was observed in 17% of the small graft group patients and 23% of the large group (p = 0.77). No difference was observed in the frequency of bile leakage or bile duct stenosis (25% versus 21%, p=0.77). Hyper-bilirubinemia and elongation of prothrombin time persisted longer in the small graft group than in the large group (p < 0.0001 for both).nnnCONCLUSIONSnOur surgical results may suggest that a graft weight ratio of 40% or less provides a lower chance of survival after living-related liver transplantation.

Living-related transplantation of left liver plus caudate lobe

Living-related liver transplantation (LRLT) has been accepted as an effective treatment of choice for pediatric patients but its feasibility for adult patients is limited because of graft size disparity. Kawasaki and colleagues have shown that the donor’s left liver (without the caudate lobe) can be used as a maximal-for-size graft to adults if the ratio of the predicted graft volume (GV) to the recipient’s standard liver volume (SV) is more than one-third. When the graft is too small, auxiliary implantation of the left liver or use of the right liver can be an option in patients under urgent situations. Recently Miyagawa and colleagues reported a patient who received a left liver with caudate lobe graft, but they did not reconstruct the drainage vein of the caudate lobe, which may cause lobe congestion and dysfunction. We report a new technique by which the left liver plus caudate lobe is implanted with complete reconstruction of the vessels relevant to the caudate lobe.

Correlation between optimal tacrolimus doses and the graft weight in living donor liver transplantation.

The optimal doses of tacrolimus (FK) needed to reach and maintain a target blood level vary among cases of living donor liver transplantation (LDLT). One hundred and twenty four LDLTs in 122 patients were included in this study. Tacrolimus was administered by continuous intravenous infusion at a rate of 2.5u2003μg/kg/h just after the operation. The time needed to reach the target blood level and the dose needed to maintain this level for 1u2003week (17–18u2003ng/mL) were defined as the initial duration (ID) and secondary dose (SD), respectively. In the first 100 LDLTs, the correlations between ID or SD and some clinical factors were examined and equations for predicting ID or SD were derived. In the latest 24 LDLTs, FK was administered using these equations and the actual and calculated ID and SD values were compared. A multiple regression analysis revealed that only the graft weight/recipient standard liver volume (GW/SLV) ratio (%) correlated with ID or SD. Stepwise regression analysis led to the equations ID (h)=0.4u2003×u2003GW/SLV ratio + 0.2; SD (μg/kg/h)=0.02u2003×u2003GW/SLV ratio – 0.4. Simple regression analysis revealed a significant correlation between the actual and calculated ID and SD values (pu2003<u20030.0001). Initial duration and SD can be estimated from equations using the GW/SLV ratio.

Cystic Dilatation of the Intrahepatic Biliary System in Biliary Atresia After Hepatic Portoenterostomy

Five cases of intrahepatic biliary cyst or cystic dilatation and one suspicious case were found (6.4%) among 93 survivors of biliary atresia. The age at manifestation of such cysts ranged from 6 months to 12 years. These cysts or cystic dilatations were treated surgically in two cases, by percutaneous transhepatic cholangiodrainage (PTCD) in two, and not treated in one. Four patients are alive; one died of biliary atresia. Twenty-nine well-documented cases of intrahepatic biliary cyst were found in the literature, including five treated by the authors. The modes of dilatation were as follows: type A, noncommunicating cyst; type B, cyst with tiny communication with the intestinal loop; and type C, cystic dilatation. Clinical symptoms were fever, jaundice, acholic stool, and cholangitis. Nineteen patients (66%) had symptoms within 4 years after the Kasai operation (first group); the modes of dilatation were mostly types A and B. However, in five of six patients with type C dilatation, symptoms developed after 10 years of age (second group). The prognosis for the second group appears poor because the condition of the liver worsens once cystic dilatation develops.

Antenatal diagnosis of biliary atresia (type I cyst) at 19 weeks' gestation : differential diagnosis and etiologic implications

At 19 weeks gestation, two cystic structures were first identified in the abdomen of a fetus. A repeat ultrasonography at 34 weeks confirmed a definite cyst communicating with the liver. The baby was born at 39 weeks, and serum direct bilirubin started to rise to 4.1 mg/dL. An operative cholangiogram at 23 days of life showed a cystically dilated choledochus with distal atresia and a relatively smooth yet hypoplastic intrahepatic biliary tree. Complete obliteration of the cystic duct was also noted. After excision of the cystic common bile duct, hepatico-jejunal anastomosis was performed, and the patient did well for 8 months postoperatively. Liver biopsy showed proliferation of the bile ductules, but no interlobular bile ducts were observed in any portal triad. A diagnosis of biliary atresia was established. Including the present case, five cases of antenatally diagnosed biliary atresia have been reported. All of them had type I cyst, and antenatal diagnosis was made at 19 to 32 weeks gestation. Differential diagnosis between biliary atresia of type I cyst and choledochal cyst with complete distal obstruction has been a matter of discussion, and recognition of the entity of antenatally diagnosed biliary atresia is of significant importance from an etiological point of view.

Simple test on the back table for justifying single hepatic-arterial reconstruction in living related liver transplantation.

1. Sollinger HW, Odorico JS, Knechtle SJ, D’Alessandro AM, Kalayoglu M, Pirsch JD. Experience with 500 simultaneous pancreas-kidney transplants. Ann Surg 1998; 228: 284. 2. Gruessner RW, Sutherland DE, Drangstveit MB, Wrenshall L, Humar AA, Gruessner AC. Mycophenolate mofetil in pancreas transplantation. Transplantation 1998; 66: 318. 3. Groth CG. The European experience with mycophenolate mofetil. European Mycophenolate Mofetil Cooperative Study Group. Transplant Proc 1996; 28: 30. 4. Vanrenterghem Y. The use of mycophenolate mofetil (CellCept) in renal transplantation. Nephron 1997; 76: 392 5. Wilmink T, Frick W. Drug-induced pancreatitis. Drug Saf 1996; 14: 406.

Excision of a choledochal cyst and simultaneous hepatic lateral segmentectomy

We treated a 4-year-old girl with a choledochal cyst (CC) with bilateral intrahepatic involvement. A severe stricture between the enormously dilated left intrahepatic bile duct and the dilated common hepatic duct was found; this necessitated prophylactic hepatic lateral segmentectomy together with excision of the CC to avoid possible stone formation in the cystically dilated left intrahepatic duct. The choice of the combined procedures was based upon long-term results of other patients in our experience. This is the first such procedure to be reported.

Intralesional corticosteroid injection with short-term oral prednisolone for infantile hemangiomas of the eyelid and orbit

Infants with hemangiomas of the eyelid and orbit are at risk for amblyopia and refractive errors. Several methods of treatment for these tumors have been associated with complications and limitations. Five infants with these hemangiomas were treated by intralesional corticosteroid injection combined with short-term oral prednisolone. In an attempt to eliminate complications, corticosteroid injections were administered. In the cases of orbital hemangioma, ultrasonography guidance was used to assist the injection. This treatment is safe, simple, and effective for infants. In addition, complications are minimized.

Gastrointestinal bleeding after living-related liver transplantation

We examined the prevalence of gastrointestinal bleeding in patients undergoing living-related liver transplantation (LRLT). Seventy-seven patients (37 male and 40 female) underwent LRLT at the University of Tokyo Hospital from January 1996 through December 1999. Forty-nine patients were children or adolescents and 28 patients were adults. The mean follow-up period was 21.3 ± 12.8 months. Nine of the 77 recipients had gastrointestinal bleeding after transplantation. The incidence of posttransplant bleeding was significantly higher in adult recipients than in pediatric recipients (25% vs 4%, P < 0.05). The ratio of graft volume to standard liver volume was significantly lower in adult recipients than in pediatric recipients (41 ± 6% vs 86 ± 26%, P < 0.05). Portal vein thrombosis (PVT) developed after LRLT in 8 patients. Variceal bleeding subsequently occurred in all 4 adult patients with PVT but in only 1 of 4 pediatric patients. Small-for-size grafts may cause transient portal hypertension, which increases the risk of gastrointestinal bleeding.

A new operational approach for the piriform sinus fistula

It has been well documented that piriform sinus fistulae often cause suppurative thyroditis; however, when a piriform sinus fistula does not present this symptom, making a correct diagnosis is very difficult. We have experienced 11 cases of a piriform sinus fistula. The conventional operational approach was performed in the initial eight patients, among which there were four recurrences in two patients. Therefore, a new operational approach was introduced for the three most recent cases and one recurrent case. First, the existence of the internal orifice of the fistula is confirmed with a laryngoscope, after which a transverse incision on the neck is made and the abscess dissected. The side wall of the piriform sinus is then opened with the help of a laryngoscope and the bottom part of the mucosa of the sinus transected with the internal orifice of the fistula, after which the fistula is removed en bloc with the bottom part of the sinus and abscess cavity. Using this operation, we experienced no complications and there has been no recurrence so far.