H. Nakatsuka

Successful Super-Small-for-Size Graft Liver Transplantation by Decompression of Portal Hypertension via Splenectomy and Construction of a Mesocaval Shunt: A Case Report

We performed a successful super-small-for-size graft liver transplantation by decompressing portal hypertension via splenectomy and a mesocaval shunt. A 46-year-old woman with Child-Pugh class C liver cirrhosis associated with Wilsons disease underwent a living donor liver transplantation (LDLT). The donor had an anomalous portal vein, hepatic vein, and bile duct, so we had to use the right lateral segment for the graft. Preoperative computed tomographic (CT) volumetry showed the volume of this area to be 433 mL; graft-to-recipient weight ratio (GRWR) was 0.72; and graft-to-standard liver volume (GV/SLV) was 39.0%. However, the real volume of the resected right lateral segment was 281 g; GRWR was 0.47; and GV/SLV was 25.3%--a super-small-for-size graft. After implantation, congestion of the small graft was severe due to excessive portal hypertension. Therefore, we tried decompressing the portal vein. First, we performed splenectomy which reduced the portal pressure which remained excessive. Second, a mesocaval shunt was constructed decreasing the portal pressure from 38 to 30 cm H2O. Additionally, we initiated continuous portal injection of prostaglandin E1. The postoperative course was not smooth, but the general status slowly recovered. Over 25 cm H2O of portal hypertension was observed until postoperative day 21 when it improved. At last, the recipient was discharged on postoperative day 156. Accurate preoperative CT volumetry is important to obtain sufficient graft volume. Our case may be one of the smallest-for-size grafts that was successfully transplanted. Management of excessive portal hypertension is important for LDLT, especially using a small-for-size graft. Splenectomy and construction of a mesocaval shunt may be useful strategies to decompress the portal vein.

Catheter-directed continuous thrombolysis following aspiration thrombectomy via the ileocolic route for acute portal venous thrombosis: report of two cases

Although acute portal venous thrombosis (PVT) is a potentially life-threatening complication that occurs after hepatobiliary surgery with portal vein (PV) reconstruction or splenectomy, no effective or universal treatments have yet been established. Transjugular or transhepatic catheter-directed thrombolysis has recently been reported to be effective for treating acute PVT. However, the efficiency of this treatment for complete PV occlusion might be limited because a poor portal venous flow prevents thrombolytic agents from reaching and dissolving thrombi. Moreover, the use of the transjugular or transhepatic route might not be suitable in patients who have undergone major hepatectomy or in those with ascites due to an increased risk of residual liver injury or intra-abdominal bleeding following puncture to the residual liver. We herein describe the cases of two patients with almost total PV occlusion caused by massive thrombi that formed after hepatobiliary surgery, who were successfully treated with catheter-directed continuous thrombolysis following aspiration thrombectomy via the ileocolic route. This treatment should be considered beneficial for treating selected patients such as the two patients described herein.

Splenic-intrahepatic left portal shunt in an adult patient with extrahepatic portal vein obstruction without recurrence after pancreaticoduodenectomy

In the last decade, a superior mesenteric-intrahepatic left portal shunt (Rex shunt) has been reported for successful management of extrahepatic portal vein obstruction in children. However, in adults, a mesocaval shunt has been generally performed for the surgical management of extrahepatic portal vein obstruction because of the complexity of the underlying disease and the difficulty of the superior mesenteric-intrahepatic left portal shunt. We herein report an adult patient who was successfully treated by splenic-intrahepatic left portal shunt with an artificial graft (6-mm polytetrafluoroethylene) for complete obstruction of the extrahepatic portal vein following pancreaticoduodenectomy. The shunt procedure not only relieved portal hypertension but also restored hepatic portal flow. In the near future, the Rex shunt should be considered for a beneficial management of extrahepatic portal vein obstruction, even in adults.

Thrombotic Microangiopathy After ABO-Incompatible Living Donor Liver Transplantation: A Case Report

Thrombotic microangiopathy (TMA) has rarely been reported in the setting of liver transplantation. Herein we have reported a successful case of TMA after ABO-incompatible living donor liver transplantation (LDLT) treated with plasma exchange and high-dose intravenous gamma-globulin infusion. A 50-year-old woman was diagnosed with hepatitis C virus-related cirrhosis. We performed an ABO-incompatible LDLT (group B to O) with preoperative plasma exchange to reduce the anti-B hemagglutinin titers to 1:8. The immunosuppressants consisted of tacrolimus, mycophenolate mofetil, and steroid. On postoperative day (POD) 8, her anti-B hemagglutinin titer suddenly increased to 1:64. The serum lactate dehydrogenase (LDH) level was grossly elevated (1518 IU/L). On POD 13, we suspected infection of an intra-abdominal hematoma (Serratia marcescens) which was drained surgically. On day 5 after the reoperation, thrombocytopenia developed with a platelet count of 3 x 10(4)/mm3. A peripheral blood film showed severe red blood cell (RBC) fragmentation. Thus, we made a clinical diagnosis of TMA and reduced the tacrolimus dose. We started intensive daily plasma exchange (4 L/d) with fresh frozen plasma and high-dose intravenous gamma-globulin infusions. One week thereafter, thrombocytopenia improved with reduced transfusion requirements. The peripheral blood film showed normal RBC morphology. The serum LDH returned to baseline levels. Four factors were considered to have caused TMA in this case: the prescription of tacrolimus, ABO-incompatible liver transplantation, bacterial infection, and surgical stress. These factors may have all contributed by causing significant endothelial injury and TMA.

Coagulation and Fibrinolytic Systems During Liver Regeneration in the Early Period after Adult Living Related Partial Liver Transplantation

In this study, we investigated the differences in the perioperative blood coagulation and fibrinolytic systems (BCF) between donor and recipient after adult living related partial liver transplantation (ALRPLT), with particular reference to serum plasminogen-activator inhibitor-1 (PAI-1) and soluble fibinogen level. The BCF were unstable in the recipient compared with the donor. The recipient fibrinolytic system was the same as the donor system except for PAI-1, which was remarkably increased on day 1 after transplantation in the recipient. The recipient is thought to have disseminated intravascular coagulation in the early period after ALRPLT. Soluble fibrinogen may be a useful marker for improvement in the BCF system. The elevation of PAI-1 in recipients on day 1 after transplantation may be a marker of injury from the shear stress from excessive portal hypertension after ALRPLT.

Living Related Pancreas Transplantation Alone With Enteric Drainage in Japan: Case Report

In this study, we report a living donor partial pancreas transplantation using intraportal donor-specific leukocyte transfusion (DSLT). The recipient was a 38-year-old woman who had type I diabetes mellitus for 17 years. Hypoglycemia occurred 2 or 3 times per week. Her hemoglobin A1c level was 9.0%, and she required 70 U of insulin almost every day. The donor was her 64-year-old father. The steroid-minimized immunosuppressive protocol included 1.5mg of thymoglobulin administered with a steroid bolus on days 0, 4, and 7 postoperatively. Steroids were never prescribed thereafter. Postoperative maintenance therapy included tacrolimus (FK506) and mycophenolate mofetil. In addition to these conventional approarches, we administered intraportal DSLT on days 0, 1, 4, and 7 after transplantation. The donor-specific leukocytes (40mL) had been separated from donor whole blood using an apheresis filter (Cellsorba EX; Asahi Kasei medical Co, Ltd, Tokyo, Japan). In the recipient operation, a segmental pancreas graft was transplanted into the right iliac cavity with enteric drainage with a pancreatic duct stent. Operation time was 6 hours. The postoperative course was uneventful. The patient was discharged on day 15 after transplantation. There was no acute rejection for six months after transplantation. The hemoglobin A1c level recovered to 5.1% with 6 U of insulin per day. At immunologic analysis, only interleukine-10 cytokine production was elevated at 7 days after transplantation. At flow cytometry cross-match analysis, the immunoglobulin M antibody decreased from day 7 after transplantation. We conclude that intraportal DSLT may be an effective adjunct to a steroid-free regimen.

Beneficial Effect of Partial Portal Decompression Using the Inferior Mesenteric Vein for Intractable Gastroesophageal Variceal Bleeding in Patients With Liver Cirrhosis

BackgroundUse of the inferior mesenteric vein (IMV) for partial portal decompression has not been recommended as a first-line option for intractable gastroesophageal variceal bleeding because of the thin diameter of the vein. Although these indications remain relevant, few reports have compared partial portal decompression using the IMV with other therapies. We propose that partial portal decompression using the IMV is a useful alternative treatment for intractable variceal bleeding.MethodsWe performed partial portal decompression using the IMV in eight patients with intractable variceal bleeding that had been uncontrolled using medical and endoscopic therapies. All patients were classified into Child’s class B or C. The surgical data, morbidity, and mortality were assessed.ResultsMean portal venous pressure significantly decreased from 26.9 ± 2.0 mmHg before the surgery to 19.8 ± 3.9 mmHg after the surgery. The operative mortality rate was 0%. The mean duration of hospital stay was 25.5 ± 13.3 days. Although one patient experienced recurrent bleeding, shunt patency was well maintained in all patients during the follow-up period (mean 28.9 ± 14.1 months). Six patients are still alive and well without ascites or hepatic encephalopathy. Two of the Child’s class C patients who underwent emergency shunt died owing to hepatic decompensation.ConclusionPartial portal decompression using the IMV can be a safe, effective way to treat intractable variceal bleeding in patients with liver cirrhosis. However, use of the shunt procedure may have the most survival benefits for cirrhotic patients with preserved liver function.

The New Method of Time-Lag Ligation for Portosystemic Shunt Using Coronary Artery Bypass Graft Occluder for Adult Living Donor Liver Transplantation

We performed a living donor liver transplantation (LDLT) for a 57-year-old man who had end-stage liver failure with portal hypertension and an inferior mesenteric vein-left testicular vein (IMV-LTV) shunt. At operation, we did not clamp the shunt but encircled it with a coronary artery bypass graft (CABG) occluder (Sumitomo Bakelite K.K., Japan), which was passed outside the body through the abdominal wall to time-lag ligation (TLL). On postoperative day (POD) 5, we observed decreased portal flow. We performed TLL of the shunt using the CABG occluder without re-laparotomy. The portal flow increased, while the portal vein pressure increased slightly. In LDLT, portosystemic shunt has been reported to be a cause of portal thrombus formation or graft liver atrophy due to decreased PV flow in the mid postoperative period. However, perioperative ligation of a portosystemic shunt may prevent regeneration of the grafted liver because of excessive portal hypertension. Therefore the technique of time-lag ligation of a portosystemic shunt using a CABG occluder may be a minimally invasive, useful method to achieve physiological liver graft regeneration.

Impact of Intraportal Donor-Specific Leukocyte Transfusion for Adult ABO-Incompatible Liver Transplantation

INTRODUCTION We have reported that repeated donor-specific leukocyte transfusions (DSLT) via the portal vein allow rapid reduction of immunosuppressants and decrease the occurrence of acute cellular rejection. Herein, we examined the immunological benefits of DSLT in adult ABO-incompatible living donor liver transplantation (LDLT). MATERIALS AND METHODS Ten adult patients (MELD score, 19.4 +/- 7.3; range, 12-29) underwent LDLT from ABO-incompatible donors from August 2003 to November 2007. The antirejection therapy included multiple perioperative plasmaphereses, splenectomy, and quadruple immunosuppression. In addition to these conventional approaches, we performed 4 intraportal administrations of DSLT after transplantation. RESULTS There was no humoral rejection in any patient. Two patients experienced mild cellular rejection requiring steroid pulse therapy. Both donor-specific immunoglobulin (Ig)M and IgG A/B antibodies in all patients decreased following transplantation by 16 fold. By flow cytometry, donor type of CD56+NK T cells existed in the liver graft showing macrochimerism at 1 month after liver transplantation. Furthermore, interleukin (IL)-10 production of Th2 type cytokines was up-regulated after transplantation. Three patients died of sepsis and infection. The 5-year survival rate was 70% by the Kaplan-Meier method. CONCLUSION Adult ABO-incompatible liver transplantation can be performed with acceptable patient and graft survival rates with a low risk of antibody-mediated rejection using intraportal administration of DSLT. Donor type CD56+NK T cells may induce tolerance by a veto or an anti-idiotype network mechanism.

Adult ABO-Incompatible Liver Transplantation by Intraportal Transfusion of Donor-Specific Antigen: A Case Report

A 55-year-old-woman suffering from fluminant hepatitis owing to autoimmune hepatitis underwent ABO-incompatible liver transplantation (LRLD) of blood type A to B. In this study, we investigated whether a new immunosuppressive strategy by intraportal transfusion of donor-specific leukocytes (DSLT) separated from whole blood would yield immunological benefit in adult ABO-LRLD. The operative course was uneventful; she was discharged at 46 days postoperatively without humoral or cellular rejection. On immunologic analysis, 54.6% intrahepatic macrochimerism of donor type CD56+ T cells was recognized at 1 month after transplantation. The interleukin-10 Th2 cytokine level was increased on postoperative day 1. Adult ABO-incompatible liver transplantation can be performed with acceptable patient and graft survival rates with a low risk of antibody-mediated rejection with our strategy of immunosuppression by intraportal administration of DSLT. Donor type CD56+ NKT cells may induce tolerance by a veto mechanism and/or an anti-idiotype network. ABO-incompatible liver transplantation may be improved by this strategy.