Hideaki Uchiyama

Real time elastography for noninvasive diagnosis of liver fibrosis

BACKGROUND/PURPOSE The accurate preoperative evaluation of liver fibrosis stage is important in determining surgical procedures. Although percutaneous liver biopsy is the gold standard, it may cause undesirable complications, such as bleeding. This study aimed to evaluate the usefulness of real-time tissue elastography for the preoperative assessment of liver fibrosis stage. METHODS We focused on a new mode of sonogram, real-time elastography, which can show tissue elasticity on images, and express the elasticity numerically. The elastic ratio of the liver for the intercostal muscle for each patient was calculated preoperatively, using the sonography device. The liver fibrosis stages were finally determined in the operative specimens from 41 patients. We examined the correlation between the elastic ratio and the histological fibrosis stage. RESULTS The lower the elastic ratio, the more advanced was the liver fibrosis stage. There was a significant correlation between the elastic ratio and the histological fibrosis stage. The area under the receiver-operating characteristics curve for the diagnosis of significant liver fibrosis using this device was superior to those conventionally determined by blood parameters. CONCLUSIONS Real-time elastography is a promising sonography-based noninvasive method for the preoperative assessment of liver fibrosis.

Primary Graft Dysfunction After Living Donor Liver Transplantation Is Characterized by Delayed Functional Hyperbilirubinemia

The purpose of this study is to propose a new concept of primary graft dysfunction (PGD) after living donor liver transplantation (LDLT), characterized by delayed functional hyperbilirubinemia (DFH) and a high early graft mortality rate. A total of 210 adult‐to‐adult LDLT grafts without anatomical, immunological or hepatitis‐related issues were included. All of the grafts with early mortality (n = 13) caused by PGD in LDLT had maximum total bilirubin levels >20 mg/dL after postoperative day 7 (p < 0.001). No other factors, including prothrombin time, ammonia level or ascites output after surgery were associated with early mortality. Thus, DFH of >20 mg/dL for >seven consecutive days occurring after postoperative day 7 (DFH‐20) was used to characterize PGD. DFH‐20 showed high sensitivity (100%) and specificity (95.4%) for PGD with early mortality. Among the grafts with DFH‐20 (n = 22), those with early mortality (n = 13) showed coagulopathy (PT‐INR > 2), compared with those without mortality (p = 0.002). Pathological findings in the grafts with DFH‐20 included hepatocyte ballooning and cholestasis, which were particularly prominent in the centrilobular zone. PGD after LDLT is associated with DFH‐20 caused by graft, recipient and surgical factors, and increases the risk of early graft mortality.

Beneficial effects of splenectomy on massive hepatectomy model in rats.

Aim:  Possible spleno‐hepatic relationships during hepatectomy remain unclear. The purpose of this study was to investigate the impact of splenectomy during massive hepatectomy in rats.

Dual hepatic artery reconstruction in living donor liver transplantation using a left hepatic graft with 2 hepatic arterial stumps

BACKGROUND A left hepatic graft in living donor liver transplantation (LDLT) often has 2 thin and short hepatic arterial stumps, which makes hepatic artery (HA) reconstructions much more difficult to perform. Consequently, some investigators regard using a left graft as a contraindication to LDLT, whereas others report that the reconstruction of only 1 HA is sufficient for most LDLTs. The aim of this retrospective study was to investigate whether 2 HAs on a left hepatic graft in an LDLT can be reconstructed safely and whether the outcomes of LDLTs are affected by reconstructing both HAs (dual reconstruction). METHODS A total of 175 LDLTs using a left graft between October 1996 and April 2008 were divided into 3 groups: group 1 (n = 104): 1 HA stump with 1 HA reconstruction; group 2 (n = 47): 2 HA stumps with dual HA reconstruction; and group 3 (n = 24): 2 HA stumps with only 1 HA reconstruction. We reconstructed HAs using microvascular surgical techniques. RESULTS With technical advancement, we have been able to reconstruct both HAs in most cases without any HA-related complications, despite the fact that complex HA reconstructions were needed. Group 3 patients had a significantly greater incidence of anastomotic biliary stricture, which was decreased by dual HA reconstructions to the same level as observed in group 1. CONCLUSION Dual HA reconstructions can be performed safely in LDLTs with a decreased incidence of anastomotic biliary stricture.

The beneficial effects of Kampo medicine Dai-ken-chu-to after hepatic resection: a prospective randomized control study.

BACKGROUND/AIMS After hepatic resection, delayed flatus and impaired bowel movement often cause problematic postoperative ileus. Kampo medicine, Dai-kenchu-to (DKT), is reported to have a various beneficial effects on bowel systems. The aim of this study was to prospectively evaluate effects of DKT after hepatic resection. METHODOLOGY Thirty-two patients who underwent hepatic resection between July 2007 and August 2008 in Tokushima University Hospital were prospectively divided into DKT group (n=16) and control group (n=16). In DKT group, 2.5 g of DKT was administered orally three times a day from postoperative day (POD) 1. Blood was examined on POD 1, 3, 5 and 7. Postoperative first flatus, bowel movement and full recovery of oral intake, hospital stays and complications were checked. RESULTS In DKT group, levels of c-reactive protein and beta-(1-3)-D-glucan on POD 3 were significantly decreased (p<0.05). Moreover, postoperative periods for the first flatus, bowel movement and the full recovery of oral intake were significantly shortened in DKT group (p<0.05). CONCLUSIONS DKT suppressed inflammatory reaction, stimulated bowel movement and improved oral intake after hepatic resection, which may decrease serious morbidity after hepatic resection.

A simple formula to calculate the liver drainage volume of the accessory right hepatic vein using its diameter alone

BACKGROUND The liver sometimes has an accessory middle or inferior right hepatic vein (RHV) in addition to the usually existing superior RHV. In liver surgery, it is important to know the parenchymal drainage volume of these accessory RHVs to avoid postoperative liver dysfunction caused by blood congestion. The purpose of this study was to determine methods to estimate parenchymal drainage volume of such accessory veins. METHODS By reviewing the preoperative multidetector-row computed tomography (MDCT) and using specialist software, we investigated the presence of accessory RHVs, the diameter, and the parenchymal drainage volume of each vein, and we determined correlations between the diameter and parenchymal drainage volume of the accessory RHVs. RESULTS Middle (median diameter, 4.9 mm) and inferior (median diameter, 5.0 mm) RHVs were present in 15% and 47%, respectively, in this study. The median parenchymal drainage volume of the superior, middle, and inferior RHVs was 401 mL, 64 mL, and 116 mL, respectively. There were positive correlations between diameters and the parenchymal drainage volume of accessory RHVs (middle RHV: y = 27.1x-45.7, r = .78, P < .05; inferior RHV: y = 34.8x-57.8, r = .80, P < .01), which made it possible to calculate the parenchymal drainage volume of these veins using their diameters alone. CONCLUSION Approximately half of the livers in this study had 1 or 2 accessory RHV(s), the parenchymal drainage volume of which was substantial. We can calculate the parenchymal drainage volume from the diameter of each accessory RHV on CT, which enables liver surgeons to determine how to manage these hepatic veins.

Living donor liver transplantation using a left hepatic graft from a donor with a history of gastric cancer operation

In some countries, because of the scarcity of cadaveric donation [1], liver transplants have been heavily dependent on living donation which has recently become an accepted procedure [2]. In such situations, selection of living donors is one of the most important matters, especially in donors with a history of an abdominal operation or malignancy [3–5]. Here we report a case of living donor liver transplantation (LDLT) using a left hepatic graft from a donor with a history of gastric cancer operation. A 60-year-old female was admitted to our hospital with decompensated hepatitis C-related cirrhosis to undergo LDLT. The preoperative Model for End-Stage Liver Disease score [6] was 18. Her husband, the only candidate living donor, was a 59-year-old man with a history

Recurrent hepatitis B following recurrence of hepatocellular carcinoma after living donor liver transplantation.

Hepatitis B virus (HBV) recurrence after liver transplantation for HBV-associated liver diseases results in decreased patient and graft survival. Herein we have reported two cases of HBV recurrence following relapse of hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT). Both cases had LDLT for end-stage liver disease secondary to HBV infection with nodules of HCC exceeding the Milan criteria. HBV prophylaxis using hepatitis B immunoglobulin with nucleos (t) ide analogues were given and HBV DNA levels were consistently undetectable after LDLT. HCC recurred at 5 months and 13 months posttransplant respectively, and chemotherapy and radiation therapy were performed. HBV recurrence occurred during the treatment of HCC. HBV DNA levels increased despite the treatment with anti-HBV agents after HBV recurrence. In hepatitis B surface antigen positive recipients, HBV prophylaxis should be intensified during the treatment of recurrent HCC.

Two-Step Hanging Maneuver for an Isolated Resection of the Dorsal Sector of the Liver

Resection of malignant lesions arising in the dorsal sector of the liver is a challenging procedure because the sector is located deep in the abdominal cavity and surrounded by the inferior vena cava (IVC) and the major hepatic veins [1 – 9]. A hanging maneuver is an innovative procedure in hepatic surgeries, in which the liver parenchyma is hung by a tape, thereby making a straight cutting line [10 – 14]. This technique was applied in two patients who had a hepatocellular carcinoma (HCC) in the dorsal sector. Patient 1 was a 46-year-old female, who was found to have an HCC, approximately 3 cm in diameter, located just above the IVC. The patient had a large inferior right hepatic vein (IRHV). The superior right hepatic vein (SRHV) and the IRHV were individually controlled with a tape after dividing several short hepatic veins from the right side of the IVC. A cotton tape was introduced from the groove between the SRHV and the middle hepatic vein (MHV) to the right and left Glisson sheaths via the space just next to the left side of the IRHV. The liver was split into the right and left hemilivers by pulling the tape upwards. Next, the tape was introduced from the space behind the confluence of the MHV and the left hepatic vein (LHV) to the space behind the left Glisson sheath via the fissure of the ligamentum venosum after dividing a few small Glisson branches into the caudate lobe from the left Glisson sheath. The liver parenchyma was divided between the medial sector and the dorsal sector by pulling the tape medially, Finally, the dorsal sector including the tumor was resected by dividing the short hepatic veins from the left side of the IVC. Patient 2 was a 59-year-old male, who was found to have an HCC, approximately 3 cm in diameter, located in the Spiegel lobe (a part of the dorsal sector) during a follow-up for chronic hepatitis B. The tumor compressed the left side of the IVC and protruded inferomedially. Cotton tape was introduced from the groove between the MHV and the LHV to the groove between the right and left Glisson sheaths via the posterior surface of the liver after dividing all the short hepatic

Microvascular Hepatic Artery Reconstruction in Living Donor Liver Transplantation

Even with the recent technical advances in the surgical procedures used for living donor liver transplantation (LDLT), hepatic artery reconstruction is still one of the most difficult procedures in LDLT (Matsuda et al., 2006; Eguchi et al., 2008). Because hepatic artery complications in liver transplantation, such as hepatic artery thrombosis (HAT) or hepatic artery dissection (HAD), often lead to devastating consequences, such as graft loss or patient death (Yanaga et al., 1990a; Settmacher et al., 2000; Stange et al., 2003), hepatic artery reconstruction should be performed using the most reliable procedure. A graft hepatic artery to be reconstructed in LDLT usually has a narrower caliber and a shorter stump compared to the arteries used during cadaveric liver transplantation. We introduced microvascular surgery for hepatic artery reconstruction in LDLT at the beginning of our LDLT program (Uchiyama et al., 2002). The use of microvascular surgery in LDLT was first reported in 1992 (Mori et al., 1992). Thereafter, many transplant centers introduced this technique for hepatic artery reconstruction in LDLT and confirmed that its application to hepatic artery reconstruction in LDLT decreased the number of hepatic artery complications (Inomoto, et al., 1996; Millis et al., 2000; Wei et al., 2004; Takatsuki et al., 2006; Panossian et al., 2009). We performed 401 cases of LDLT between October 1996 and June 2011 and almost all hepatic artery reconstructions were performed by microvascular surgery under a microscope. Microvascular surgery for hepatic artery reconstruction has been performed by general surgeons in our department. In this chapter, we present our microvascular surgical techniques used for hepatic artery reconstructions in LDLT and the outcomes of these reconstructions in 401 LDLT cases.