Hirotaka Tokai

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.

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;

Multicentric occurrence and spread of hepatocellular carcinoma in whole explanted end-stage liver

Aim:  Hepatocellular carcinoma (HCC) arising from the end stages of liver cirrhosis is a fair indication for liver transplantation (LT). To pathologically investigate the multicentric occurrence of relatively early staged HCC in cirrhosis, we studied whole explanted livers.

Compressive stenosis of the inferior vena cava due to localized ascites after living-donor liver transplantation

A 54-year-old woman was admitted to our hospital following the diagnosis of decompensated liver cirrhosis with hepatitis C. She underwent living-donor liver transplantation, performed using the left hepatic lobe with the middle hepatic vein donated by her husband. After the transplantation, the patient suffered from massive ascites with liver dysfunction. Computed tomography demonstrated stenosis of the suprahepatic inferior vena cava (IVC) with focal collection of fluid. A second laparotomy was performed 19 days after the transplantation. When the encapsulated localized ascites on both sides of the IVC was opened, the ascites was flushed away. Subsequently, the grafted liver was easily mobilized and it was placed in the natural position without any tension, and the pressure gradient of the IVC was improved. Herein, we report a very rare case of compression stenosis of the IVC resulting in Budd-Chiari syndrome caused by localized encapsulated ascites.

Case of plasmablastic lymphoma of the sigmoid colon and literature review

Plasmablastic lymphoma (PBL) is a rare form of non-Hodgkins lymphoma that is associated with human immunodeficiency virus (HIV) infection. Although PBL is most commonly observed in the oral cavity of HIV-positive patients, it can also be observed at extra-oral sites in HIV-negative patients. This report represents an unusual case of HIV-negative PBL that occurred in the sigmoid colon. This patient had a history of systemic lupus erythematosus and an underlying immunosuppressive state from long term steroid therapy. The lymphoma cells were positive for CD138, kappa light chain restriction and Epstein-Barr virus and negative for CD20/L26, CD3, CD79a, UCHL1 (CD45RO) and cytokeratin (AE1/AE3). The patient died approximately 2 mo after the operation. In the present paper, we review cases of PBL of the colon in HIV-negative patients.

Living Donor Liver Transplantation for Hepatitis C Virus Cirrhosis with a Huge Portal Vein Aneurysm

Received November 25, 2007; accepted January 20, 2008.A57-year-oldfemalewasdiagnosedwithhepatocellularcarcinoma associated with hepatitis C virus–related cir-rhosis. She underwent ablation therapy several times,including 4 repeated courses of percutaneous ethanolinjection, and was finally referred to our hospital forliver transplantation. During the preoperative evalua-tion, a huge extrahepatic portal vein aneurysm (PVA)and mural thrombosis were detected on computed to-mographic angiography and magnetic resonance imag-ing angiography (Fig. 1). Massive ascites and a recana-lized umbilical vein were also noted. She underwentliving donor liver transplantation using her daughter’sright lobe graft. During surgery, the confluence of thesuperior mesenteric vein and splenic vein seemed to benormal and intact, so the whole PVA was resected, andthe mural thromboses were removed. Thereafter, directend-to-end anastomosis between the recipient portalvein and graft portal vein was successfully accom-plished without tension. The postoperative course wasuneventful until she developed portal vein thrombosisdue to anastomotic stenosis 1 year after the transplan-tation. The complication was successfully reversed bysystemic thrombolytic therapy using recombinant tis-sue plasminogen activator combined with subsequentpercutaneous transhepatic balloon dilatation. Sincethen, the patient has been doing well with normal liverfunction for the past 2 years.Abnormality of the portal vein is often observed inliver transplant candidates but mainly as stenosis orthrombosis in chronic diseases.

Multidisciplinary therapy for granulocyte-colony-stimulating factor producing carcinosarcoma of the esophagus: report of a case.

The granulocyte‐colony‐stimulating factor (G‐CSF)‐producing esophageal carcinosarcoma is extremely rare in esophageal cancer. In the present case, multidisciplinary therapy, which is surgical resection with preoperative chemotherapy, has been effectively treatment to granulocyte‐colony‐stimulating factor producing esophageal carcinosarcoma of the esophagus.

The impact of hepatic denervation on the accumulation of hepatic progenitor cells during liver regeneration in rats.

BACKGROUND/AIMS All autonomic hepatic nerves are transected following liver transplantation. Recent studies have shown the relationship between an inhibition of autonomic nerves and the accumulation of hepatic progenitor cells (HPC). This study aims to elucidate the influence of hepatic denervation on the accumulation of HPC in the process of liver regeneration. METHODOLOGY Male Sprague-Dawley rats underwent hepatic denervation. Immediately after either denervation (DN group, n=30) or a sham operation (control group, n=30), a two-thirds hepatectomy was performed, and these were sacrificed chronologically. An immunohistochemical analysis of HPC was performed with a mouse monoclonal OV6 type antibody. RESULTS The liver per body weight ratio gradually increased in both groups. On postoperative day (POD) 7, the DN group showed a significantly higher ratio. The HPC expression gradually increased in both groups. The maximal HPC number was observed on POD 7 in the DN group and on POD 3 in the control group. Although there was no significant difference in the HPC numbers between the DN and control group until POD 3, the number of HPC were significantly higher in livers of the denervated rats than in those of the sham operated rats between POD 5 and 14. CONCLUSIONS The hepatic autonomic nerves were thus suggested to play an important role in the accumulation of HPC during liver regeneration in rats.

Efficacy and limitation of bone marrow transplantation in the treatment of acute and subacute liver failure in rats.

Aim:  Recent reports have shown that bone marrow cells (BMC) retain the potential to differentiate into hepatocytes. Thus, the BMC have been recognized as an attractive source for liver regenerative medicine. However, it has not been clarified whether BMC transplantation can be used to treat liver damage in vivo. In the present study, we explored whether BMC possess therapeutic potential to treat acute and/or subacute liver failure.

Endoscopic Sphincterotomy Using the Rendezvous Technique for Choledocholithiasis during Laparoscopic Cholecystectomy: A Case Report.

A 50-year-old male was examined at another hospital for fever, general fatigue and slight abdominal pain. He was treated with antibiotics and observed. However, his symptoms did not lessen, and laboratory tests revealed liver dysfunction, jaundice and an increased inflammatory response. He was then admitted to our hospital and underwent an abdominal computed tomography scan and magnetic resonance cholangiopancreatography (MRCP), which revealed common bile duct (CBD) stones. He was diagnosed with mild acute cholangitis. As the same time, he was admitted to our hospital and an emergency endoscopic retrograde cholangiopancreatography was performed. Vater papilla opening in the third portion of the duodenum and presence of a peripapillary duodenal diverticulum made it difficult to perform cannulation of the CBD. In addition, MRCP revealed that the CBD was extremely narrow (diameter 5 mm). We therefore performed laparoscopic cholecystectomy and endoscopic sphincterotomy using the rendezvous technique for choledocholithiasis simultaneously rather than laparoscopic CBD exploration. After the operation, the patient was discharged with no complications. Although the rendezvous technique has not been very commonly used because several experts in the technique and a large operating room are required, this technique is a very attractive and effective approach for treating choledocholithiasis, for which endoscopic treatment is difficult.