Jiro Yoshimoto

Left lobe adult‐to‐adult living donor liver transplantation: Should portal inflow modulation be added?

Recently, the successful application of portal inflow modulation has led to renewed interest in the use of left lobe grafts in adult‐to‐adult living donor liver transplantation (LDLT). However, data on the hepatic hemodynamics supporting portal inflow modulation are limited, and the optimal portal circulation for a liver graft is still unclear. We analyzed 42 consecutive adult‐to‐adult left lobe LDLT cases without splenectomy or a portocaval shunt. The mean actual graft volume (GV)/recipient standard liver volume (SLV) ratio was 39.8% ± 5.7% (median = 38.9%, range = 26.1%‐54.0%). The actual GV/SLV ratio was less than 40% in 24 of the 42 cases, and the actual graft‐to‐recipient weight ratio was less than 0.8% in 17 of the 42 recipients. The mean portal vein pressure (PVP) was 23.9 ± 7.6 mm Hg (median = 23.5 mm Hg, range = 9‐38 mm Hg) before transplantation and 21.5 ± 3.6 mm Hg (median = 22 mm Hg, range = 14‐27 mm Hg) after graft implantation. The mean portal pressure gradient (PVP − central venous pressure) was 14.5 ± 6.8 mm Hg (median = 13.5 mm Hg, range = 3‐26 mm Hg) before transplantation and 12.4 ± 4.4 mm Hg (median = 13 mm Hg, range = 1‐21 mm Hg) after graft implantation. The mean posttransplant portal vein flow was 301 ± 167 mL/minute/100 g of liver in the 38 recipients for whom it was measured. None of the recipients developed small‐for‐size syndrome, and all were discharged from the hospital despite portal hyperperfusion. The overall 1‐, 3‐, and 5‐year patient and graft survival rates were 100%, 97%, and 91%, respectively. In conclusion, LDLT with a left liver graft without splenectomy or a portocaval shunt yields good long‐term results for adult patients with a minimal donor burden. Liver Transpl 18:305–314, 2012.

Conversion of elective laparoscopic to open cholecystectomy between 1993 and 2004.

Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallbladder disease. The identification of factors that reliably predict the likely need to convert LC to an open procedure would provide short‐term benefits in terms of patient education and postoperative expectations.

Effects of intermittent Pringle's manoeuvre on cirrhotic compared with normal liver

Although patients with liver cirrhosis are supposed to tolerate ischaemia–reperfusion poorly, the exact impact of intermittent inflow clamping during hepatic resection of cirrhotic compared with normal liver remains unclear.

Relationship between the histological degrees of hepatitis and the postoperative recurrence of hepatocellular carcinoma in patients with hepatitis C

The relationship between the recurrence of hepatocellular carcinoma (HCC) and the degree of inflammation was evaluated in resected livers with the hepatitis C virus (HCV) -associated HCC. Seventy-three patients with HCV-associated HCC who were followed up for more than 2 years were selected for this study. In these cases, the degree of chronic hepatitis in noncancerous regions at the time of surgery was classified according to the New Inuyama Classification as follows, the degree of necroinflammatory activity (Grading) was graded from A0 to A3, and the degree of fibrosis (Staging) was staged on F0-F4. In addition, among these patients, 41 patients who were followed by blood tests every 3 months were divided into two groups (high or low group) according to annual average levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), the platelet counts (Plt), and alpha-fetoprotein (AFP). As a result, cancer-free survival rate was significantly lower in the high-grade group (A3) than in the low-grade group (A1 or 2) (P=0.01). The high ALT (>80 IU) group and the high AFP (>20 mg/ml) group also had significantly worse cancer-free survival rate than the low ALT group and the low AFP group (P=0.04 for ALT, P=0.03 for AFP). A multivariate analysis for the prognostic values revealed the AFP level (P=0.02) and the Grading (P=0.04) were useful as independent prognostic factors concerning recurrence. In conclusion, the degree of inflammatory activity (Grading) is considered to be a useful factor regarding recurrence after liver resection in patients with HCC. Furthermore, the inhibition of inflammation in remnant liver may also contribute to the prevention of recurrence.

Impact of a left-lobe graft without modulation of portal flow in adult-to-adult living donor liver transplantation.

In adult‐to‐adult living donor liver transplantation (LDLT), left‐lobe grafts can sometimes be small‐for‐size. Although attempts have been made to prevent graft overperfusion through modulation of portal inflow, the optimal portal venous circulation for a liver graft is still unclear. Hepatic hemodynamics were analyzed with reference to graft function and outcome in 19 consecutive adult‐to‐adult LDLTs using left‐lobe grafts without modulation of graft portal inflow. Overall mean graft volume (GV) was 398 g, which was equivalent to 37.8% of the recipient standard liver volume (SV). The GV/SV ratio was less than 40% in 13 of the 19 recipients. Overall mean recipient portal vein flow (PVF) was much higher than the left PVF in the donors. The mean portal contribution to the graft was markedly increased to 89%. Average daily volume of ascites revealed a significant correlation with portal vein pressure, and not with PVF. When PVP exceeds 25 mmHg after transplantation, modulation of portal inflow might be required in order to improve the early postoperative outcome. Although the study population was small and contained several patients suffering from tumors or metabolic disease, all 19 patients made good progress and the 1‐year graft and patient survival rate were 100%. A GV/SV ratio of less than 40% or PVF of more than 260 mL/min/100 g graft weight does not contraindicate transplantation, nor is it necessarily associated with a poor outcome. Left‐lobe graft LDLT is still an important treatment option for adult patients.

Postoperative recurrence pattern and prognosis of patients with hepatocellular carcinoma, with particular reference to the hepatitis viral infection status

Various modalities have been employed effectively according to the tumour recurrence status in patients with hepatocellular carcinoma (HCC) undergoing hepatectomy. Therefore, their overall prognosis depends largely on the pattern of recurrence/treatment. We investigated the patterns of recurrence and prognosis in HCC patients, especially in relation to the hepatitis virus infection status.

Clinical significance of immunohistochemically detectable lymph node metastasis in adenocarcinoma of the ampulla of Vater.

The aim of this study was to assess the impact of immunohistochemically identified lymph node metastasis on survival in patients with carcinoma of the ampulla of Vater.

Hepatectomy using traditional Péan clamp–crushing technique under intermittent Pringle maneuver

BACKGROUND The clamp-crushing technique has been proved to be the most cost-efficient approach for hepatectomy. If the advantageous characteristics, such as lower blood loss and morbidity, could be utilized, this method could be ideal. METHODS The records of 380 patients who underwent hepatectomy using the clamp-crushing technique with intermittent inflow occlusion between 2002 and 2006 were retrospectively reviewed. One hundred fifty patients underwent major hepatectomy, and 230 underwent minor hepatectomy. RESULTS Thirteen (3.4%) patients received red cell transfusion, and 21 (5.5%) patients received fresh frozen plasma. According to Claviens classification system, grade I complications occurred in 42 (11.1%), grade II in 32 (8.4%), grade III in 14 (3.7%), grade IV in 1 (0.3%), and grade V in 2 (0.5%) patients. Female sex, preoperative albumin-to-globulin ratio, and type of resection were independent factors predictive of blood loss. CONCLUSIONS The present patient series, who underwent traditional Péan clamp-crushing technique under intermittent Pringle maneuver, had a low risk of complications. This procedure is an acceptable technique for hepatic parenchymal transection.

Direct measurement of hepatic blood flow during living donor liver transplantation in children.

BACKGROUND The changes in liver blood flow associated with living donor liver transplantation (LDLT) in children have not yet been studied. The aim of the present study was to investigate changes in hepatic hemodynamics before and after pediatric partial liver transplantation. METHODS In 7 pediatric recipients with congenital cholestasis and native liver Child-Pugh classes B and C, portal vein flow (PVF) and hepatic arterial flow (HAF) were measured using an ultrasonic transit time flow meter before removal of the native liver and after transplantation and compared with donor left PVF and donor left HAF. RESULTS The mean portal contribution to total hepatic blood flow was markedly decreased in the recipient native liver compared with that in the donor (69% +/- 15% vs 32% +/- 15%; P = .0003) and after reperfusion changed to almost the same ratio as that in the donor liver (73% +/- 18%; P < .0001). CONCLUSION The extreme imbalance between PVF and HAF that is common in implanted partial liver in adult LDLT recipients was not observed in pediatric LDLT. After transplantation of an appropriately sized liver graft, the portal contribution to total liver blood flow normalized to the value for normal liver.

Effect of Jejunal and Biliary Decompression on Postoperative Complications and Pancreatic Leakage Arising from Pancreatojejunostomy after Pancreatoduodenectomy

BackgroundSince its introduction, reconstruction after pancreatoduodenectomy has undergone numerous modifications, leading to a dramatic decline in the mortality rate. However, the reported morbidity rate, due mainly to pancreatic leakage, still remains high.MethodsBetween January 1999 and April 2005, 102 consecutive patients underwent pancreatojejunostomy after pancreatoduodenectomy. Patients treated by biliary decompression alone (n = 58) were compared with patients treated by jejunal decompression alone (n = 40). Four patients who underwent both biliary and jejunal decompression were excluded from the study.ResultsPatients who underwent jejunal decompression had a significantly lower incidence of overall postoperative complications (P = 0.028), pancreatic leakage (P = 0.009), and infection (P = 0.011) than patients who underwent biliary decompression. Only one patient who underwent biliary decompression died as a direct result of pancreatic leakage.ConclusionsDiscontinuation of biliary decompression with postoperative jejunal decompression using tube jejunostomy may be a good option in patients undergoing pancreatoduodenectomy, because it appears to reduce the incidence of overall postoperative complications, pancreatic leakage, and infection.