Mizuki Ninomiya

Accurate preoperative estimation of liver-graft volumetry using three-dimensional computed tomography

Background. The aim of this study was to clarify the value of three-dimensional computed-tomography (3D-CT) volumetry for size matching in living-donor liver transplantation (LDLT). Methods. 3D-CT volumetry was applied to 25 donors who underwent hepatectomy for a living relative needing an orthotopic liver transplantation. Fifteen patients underwent extended left lobectomy, one patient an extended left lateral lobectomy, and nine patients right lobectomy. 3D-CT imaging was performed with the workstation ZIO M900 (Zio Software Inc., Tokyo, Japan). The estimated volume of the grafts in two-dimensional (2D) and 3D images were compared, and an error ratio was calculated. Results. 3D-CT imaging revealed the anatomy of the hepatic vein bifurcation and the shape of the graft. The error ratio was 12.8±2.3% in 3D, compared with 19.4±2.5% in 2D. As such, 3D-CT volumetry appears to be more exact than conventional 2D-CT volumetry, but volumetry by 3D-CT still produces an error ratio of approximately 13%. The weight transition of the rats’ livers under preservation in University of Wisconsin (UW) solution indicated that the graft volume seems to decrease during perfusion with UW solution. Mismatch of the cutting line and volume reduction by dehydration (approximately 5% reduction 1 hour after perfusion) seems to cause the error in 3D-CT volumetry. Conclusions. Three-dimensional CT volumetry is useful for size matching in cases of living-related orthotopic liver transplantation.

Use of steatotic graft in living-donor liver transplantation.

Background. The degree of fatty infiltration in hepatic grafts is known to be an important risk factor for primary graft nonfunction in cadaveric liver transplantation. However, the effect of hepatic steatosis in living-donor liver transplantation (LDLT) has not yet been well defined. In this study, we evaluated the impact that the degree of hepatic graft steatosis has on the outcome of LDLT. Methods. Sixty consecutive donors and recipients who underwent LDLT between October 1996 and August 2001 at Kyushu University Hospital were the subjects of this study. The pathologic findings of the prereperfusion biopsy of the graft were classified into the following three groups according to the degree of macrovesicular steatosis: None (n=23), 0% steatosis; Mild (n=23), 0% to 20% steatosis; and Moderate (n=6), 20% to 50% steatosis. Liver function tests including total bilirubin (at postoperative day [POD] 7), the peak alanine aminotransferase (ALT) and prothrombin time (at POD 3), and both patient and graft survival were compared among the groups. Furthermore, we also compared the donor parameters including the peak ALT and total bilirubin (at POD 3) and the operative time, blood loss, and length of hospital stay after surgery. Results. The 1-year patient and graft survival were comparable among the groups. The peak ALT was significantly higher in the Moderate group (606±641 IU/L) than in the None (290±190 IU/L) and Mild (376±296 IU/L) groups. Total bilirubin (POD 7) and prothrombin time (POD 3) were comparable among the groups. The donor parameters were comparable among the groups except for the fact that the donor body weight of the Mild and Moderate groups were significantly heavier (P <0.0001) than that of the None group. Conclusions. In conclusion, the use of a fatty liver graft up to the moderate level can be justified in LDLT, even though ischemia-reperfusion injury tends to be severe in such grafts.

Prognostic Nutritional Index: A Tool to Predict the Biological Aggressiveness of Gastric Carcinoma

PurposeThe prognostic nutritional index (PNI), which is calculated based on the serum albumin concentration and the peripheral blood lymphocyte count, has been used to assess the immunological and nutritional condition of patients with digestive diseases. However, its value as an indicator of aggressiveness in gastric carcinoma has not been fully investigated.MethodsTwo hundred and forty-eight cases of gastric carcinoma were studied with regard to the relationship between the preoperative PNI value and the clinicopathological characteristics of the patients.ResultsA lower preoperative PNI value significantly correlated with greater tumor depth, lymph node metastasis, lymphatic permeation, and venous invasion. Moreover, the PNI value proved to be an independent prognostic indicator in gastric carcinoma.ConclusionThe PNI value can be a useful tool to predict the prognosis of patients with gastric carcinoma.

Clinical significance and potential of hepatic microRNA-122 expression in hepatitis C

Background and aims: MicroRNAs are small non‐coding RNA molecules that post‐transcriptionally regulate gene expression. Liver‐specific microRNA‐122 (miR‐122) has been shown to facilitate the replication of hepatitis C virus (HCV) in human hepatoma cells in vitro. However, the clinical significance of hepatic miR‐122 on HCV in human body is unclear.

Left Lobe Living Donor Liver Transplantation in Adults

Adult left lobe (LL) living donor liver transplantation (LDLT) has not generally been recognized as a feasible procedure because of the problem of graft size. The objectives of this study were to assess the feasibility and short‐ and long‐term results of adult LL LDLT in comparison with right lobe (RL) LDLT. Data on 200 consecutive LL LDLTs, including five retransplants, were retrospectively compared with those of 112 RL LDLTs, in terms of survival, complications and donor morbidity. The mean graft weight to standard volume ratio of LL grafts was 38.7% whereas that of RL grafts was 47.6% (p < 0.0001). The 1‐, 5‐ and 10‐year patient survival rates of LL LDLT were 85.6%, 77.9% and 69.5%, respectively, which were comparable to those of RL LDLT (89.8%, 71.3% and 70.7%, respectively). The incidence of small‐for‐size syndrome was higher in LL LDLT (19.5%) than in RL LDLT (7.1%) (p < 0.01). The overall donor morbidity rates were comparable between LL (36.0%) and RL (34.8%), whereas postoperative liver function tests and hospital stay were significantly better (p < 0.0001) in LL donors. In conclusion, adult LL LDLT has comparable outcomes to that of RL LDLT. LL LDLT is viable and is the first choice in adult LDLT.

Feasibility of duct-to-duct biliary reconstruction in left-lobe adult-living-donor liver transplantation.

A Roux-en-Y choledochojejunostomy (CDJ) has been the sole method of choice for the reconstruction of the bile duct in living-donor liver transplantation (LDLT) using left-lobe grafts. In this study, we evaluated the feasibility of duct-to-duct (DD) biliary reconstruction in adult-to-adult LDLT using left-lobe grafts. Between October 1996 and October 2001, 46 adult-to-adult LDLTs using the left lobe were performed at our institution. The DD biliary reconstruction (hepaticocholedochostomy) over a T-tube was performed for seven of the last nine recipients (DD group, n=7), whereas the conventional Roux-en-Y CDJ was used for the remaining cases (CDJ group, n=39). The technical problems and the incidence of biliary complications were compared between the groups. Bile leakage developed in only 1 of 7 (14%) in the DD group (leakage from a T-tube exit site), whereas it occurred in 8 of 39 (20%) in the CDJ group. Up to now, no patients from the DD group developed anastomotic stricture, whereas twelve (30.7%) patients from the CDJ group did. Other complications included bleeding from the Roux-en-Y jejunojejunostomy (n=1) and anastomotic occlusion caused by an internal stent (n=1), and both complications were associated with CDJ. In conclusion, DD anastomosis is a simple and viable option for biliary reconstruction in left-lobe LDLTs. A long-term follow-up, especially regarding the incidence of biliary stricture, is thus warranted in such patients.

Deceleration of regenerative response improves the outcome of rat with massive hepatectomy.

Small residual liver volume after massive hepatectomy or partial liver transplantation is a major cause of subsequent liver dysfunction. We hypothesize that the abrupt regenerative response of small remnant liver is responsible for subsequent deleterious outcome. To slow down the regenerative speed, NS‐398 (ERK1/2 inhibitor) or PD98059 (selective MEK inhibitor) was administered after 70% or 90% partial hepatectomy (PH). The effects of regenerative speed on liver morphology, portal pressure and survival were assessed. In the 70% PH model, NS‐398 treatment suppressed the abrupt replicative response of hepatocytes during the early phase of regeneration, although liver volume on day 7 was not significantly different from that of the control group. Immunohistochemical analysis for CD31 (for sinusoids) and AGp110 (for bile canaliculi) revealed that lobular architectural disturbance was alleviated by NS‐398 treatment. In the 90% PH model, administration of NS‐398 or PD98059, but not hepatocyte growth factor, significantly enhanced survival. The abrupt regenerative response of small remnant liver is suggested to be responsible for intensive lobular derangement and subsequent liver dysfunction. The suppression of MEK/ERK signaling pathway during the early phase after hepatectomy makes the regenerative response linear, and improves the prognosis for animals bearing a small remnant liver.

Living Donor Hepatectomies with Procedures to Prevent Biliary Complications

BACKGROUND Biliary complications in donor hepatectomies are still common, and occur in approximately 5% of the procedures. STUDY DESIGN To evaluate the usefulness of the management and surgical procedures to prevent the biliary complications in donor hepatectomies, a total of 343 donors were retrospectively studied. The clinical and surgical parameters of the donors and the postoperative biliary complications were evaluated. RESULTS Fourteen donors had biliary complication (BC) during the follow-up period (4.1%). Donors were divided into 2 groups; donors without BC (non-BC group; n = 329) and donors with BC (BC group; n = 14). Mean peak level of total bilirubin, mean duration of hospital stay after surgery, and medical cost in the BC group were significantly higher than in the non-BC group (p < 0.01). As improved procedures to prevent the BC were established at 2005, including the use of a real-time cholangiography by the C-arm, a minimized dissection of the hepatic vessels, the meticulous closure of the bile duct, and/or the use of Pringle maneuver during the parenchymal transection, the donors were divided into 2 groups before and after these establishments (the early period, n = 173; the later period, n = 170). Refinements in the management and surgical procedures reduced the occurrence of biliary complications from 6.4% during the early period to 1.8% during the later period (p < 0.01), and no biliary complications in the last 69 consecutive donors were observed. CONCLUSIONS Technical refinements described in this study might be useful to prevent the occurrence of biliary complications in a donor hepatectomy. It is particularly important to preserve the blood supply for the biliary tract of both the graft and the remnant liver.

Bacterial Sepsis after Living Donor Liver Transplantation: The Impact of Early Enteral Nutrition

BACKGROUND Bacterial sepsis is a significant problem that must be addressed after living donor liver transplantation (LDLT). STUDY DESIGN A retrospective analysis of 346 adult-to-adult LDLT patients was performed. RESULTS Forty-six patients (13.3%) experienced bacterial sepsis, with primary and secondary origins in 23.9% and 76.1%, respectively. Gram-negative bacteria accounted for 71.7% of the bacteria isolated. The 2-year cumulative graft survival rate in patients with bacterial sepsis was 45.7%. Patients with bacterial sepsis secondary to pneumonia (n = 12) had poorer 2-year graft survival rates (16.7%) than did those with primary or other types of secondary sepsis (p = 0.004). Multivariate analysis showed that intraoperative massive blood loss >10L (p < 0.001) and no enteral feeding started within 48 hours after transplantation (p = 0.005) were significant risk factors for bacterial sepsis. Among patients who received enteral nutrition, the incidences of bacterial sepsis in patients who received enteral nutrition within 48 hours (n = 135) or later than 48 hours (n = 57) were 5.9% and 21.0%, respectively (p = 0.002). The incidence of early graft loss was 8-fold higher in recipients with massive intraoperative blood loss without early enteral nutrition (p < 0.001). CONCLUSIONS Early enteral nutrition was associated with significantly reduced risk of developing bacterial sepsis after LDLT.

Comparative evaluation of expanded criteria for patients with hepatocellular carcinoma beyond the Milan criteria undergoing living-related donor liver transplantation.

Shirabe K, Taketomi A, Morita K, Soejima Y, Uchiyama H, Kayashima H, Ninomiya M, Toshima T, Maehara Y. Comparative evaluation of expanded criteria for patients with hepatocellular carcinoma beyond the Milan criteria undergoing living‐related donor liver transplantation.
Clin Transplant 2011: 25: E491–E498.