N. Kokudo

Pringle's manoeuvre in living donors

The safety of the donor is paramount in living donor liver transplantation. The most important risk to the donor during hepatectomy is bleeding, and the inflow occlusion technique (Pringles manoeuvre) has been reported to decrease bleeding without inducing liver injury in liver surgery. However, most transplant centres are doing donor hepatectomies without this technique for fear that it would result in ischaemic injury to the graft. We have done 46 living donor hepatectomies with Pringles manoeuvre without any negative outcome on the quality of the graft. Surgeons should not hesitate to apply this technique in living donor hepatectomy.

Randomized clinical trial of the effect of a saline‐linked radiofrequency coagulator on blood loss during hepatic resection

Use of a saline‐linked radiofrequency coagulator (dissecting sealer) has been suggested to reduce blood loss during hepatic resection. A randomized clinical trial was conducted to assess the effects of using the device on the amount of blood loss.

Impact of hospital volume on hospital mortality, length of stay and total costs after pancreaticoduodenectomy

High morbidity and mortality rates after pancreaticoduodenectomy (PD) have led to concentration of this surgery in high‐volume centres, with improved outcomes. The extent to which better outcomes might be apparent in a healthcare system where the mortality rate is already low is unclear.

Proposal to modify the International Union Against Cancer staging system for perihilar cholangiocarcinomas

The International Union Against Cancer (UICC) staging system for perihilar cholangiocarcinoma changed in 2009. The aim of this study was to validate and optimize the UICC system for these tumours.

Venous reconstruction based on virtual liver resection to avoid congestion in the liver remnant

Hepatic vein (HV) reconstruction may prevent venous congestion following resection of liver tumours that encroach on major HVs. This study aimed to identify criteria for venous reconstruction based on preoperative evaluation of venous congestion.

Prediction of hepatic artery thrombosis by protocol Doppler ultrasonography in pediatric living donor liver transplantation.

Abstract Hepatic arterial thrombosis (HAT) after liver transplantation is a life-threatening event. Previous reports have suggested that the resistive index (RI) of the hepatic artery predicts HAT. Doppler ultrasonography (US) to measure RI, however, is not routinely performed. The subjects were 70 pediatric patients who underwent living donor liver transplantation (LDLT). Protocol Doppler US was performed once or twice a day for 2 weeks postoperatively and 692 records were examined. Changes in RI values were examined separately in patients with and without HAT complications. The incidence of HAT was 10% (seven of 70). HAT was diagnosed an average of 6.2 days after LDLT. In patients without HAT complications (n = 63), average RI levels at 14 days after LDLT were 0.71 ± 0.1 (records, n = 625). In patients with HAT complications, RI decreased gradually within 2 days before the onset of HAT. RI values of less than 0.6 predicted HAT within 2 days before onset, with 83% sensitivity and 85% specificity. RI during the first 2 weeks after LDLT is a sensitive predictor for HAT. Thrombectomy and reanastomosis should be considered when RI values are less than 0.6 in Doppler US.

Pringle's maneuver and selective inflow occlusion in living donor liver hepatectomy

While inflow occlusion techniques such as Pringles maneuver are accepted methods of reducing bleeding without inducing liver injury during liver surgery, donor hepatectomy for living donor liver transplantation is currently performed without inflow occlusion for fear that injury to the graft may result. We have performed donor hepatectomy for 12 years using selective intermittent inflow occlusion, a technique in which the portion used to form the graft is perfused during hepatectomy. Starting in November 2000, we applied intermittent Pringles maneuver to donor hepatectomy in 81 cases of living donor liver transplantation. We reviewed our experience with Pringles maneuver and selective inflow occlusion techniques in donor hepatectomy in living donor liver transplantation. The quality of the grafts was assessed and compared by determining maximum postoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values. Neither primary nonfunction nor dysfunction occurred. Maximum AST values in the recipients were the same whether the liver segments that formed the grafts were totally ischemic during dissection (total ischemia), partially ischemic (partial ischemia), perfused only with arterial blood flow (portal ischemia), or not ischemic at all (no ischemia). Maximum ALT values in the recipients of the total ischemia group was lower, albeit not significantly, than in other groups. Total inflow occlusion can be applied to living donor hepatectomy without causing graft injury. In conclusion, because the transection surface is blood‐free, there is decreased risk to the donor during living donor liver transplantation surgery, and surgeons should not hesitate to apply this technique because it contributes to donor safety. (Liver Transpl 2004;10:771–778.)

Contrast-enhanced intraoperative ultrasonography using perfluorobutane microbubbles for the enumeration of colorectal liver metastases.

Intraoperative ultrasonography (IOUS) is considered the standard for the identification of liver metastases. Use of lipid‐stabilized perfluorobutane microbubbles as an ultrasound contrast agent may improve this. The value of contrast‐enhanced IOUS (CE‐IOUS) in enumerating colorectal liver metastases was studied here.

Adult Right Living-Donor Liver Transplantation With Special Reference to Reconstruction of the Middle Hepatic Vein

Two hundred fifty‐three consecutive living‐donor liver transplant recipients with a right liver graft (RLG) were divided into three groups: an extended right liver graft (ERLG) group (n = 47) in which the middle hepatic vein (MHV) trunk was included in the graft, a modified right liver graft (MRLG) group (n = 114) in which the MHV tributaries were reconstructed with cryopreserved homologous veins and a simple RLG group (n = 92) in which the MHV tributaries were sacrificed. The volume of the anterior sector was significantly impaired in the RLG group compared to the other two groups, whereas the volume of the posterior sector was significantly improved in the RLG group, indicating that the impaired anterior sector regeneration by MHV deprivation was compensated by the posterior sector regeneration. The regeneration rate of the anterior sector was highest in the ERLG group (92%), moderate in the MRLG group (71%) and lowest in the RLG group (52%). The whole graft regeneration rate of the ERLG group was significantly higher than that of the other two groups. Poor regeneration, however, was not correlated with delayed functional recovery or long‐term outcome. Short‐term, the patency of reconstructed MHV tributaries was over 90%, but occlusion occurred frequently over the long‐term, especially in V5.

Thrombotic microangiopathy after living-donor liver transplantation.

Thrombotic microangiopathy (TMA) is an infrequent but severe life‐threatening disorder in solid organ transplant recipients. Few studies of TMA in living donor liver transplant (LDLT) recipients, however, have been reported. We investigated the clinical characteristics and prognostic factors of TMA after LDLT. Among 393 adult LDLT recipients, 30 patients (7.6%) were identified to have TMA. The 1‐, 3‐ and 5‐year survival rates of these patients were lower (60.6%, 52.5% and 47.7%, respectively) than those of patients without TMA (93.0%, 89.0% and 87.3%, respectively). Multivariate analysis confirmed that reduced administration of fresh frozen plasma and sensitization against HLA are closely related with TMA (odds ratio [OR]: 2.6 and 16.1, respectively). However, a review of the cases revealed that individual responses to treatment varied considerably and the main etiologies were difficult to determine. A comparison of the clinical factors suggested that late onset (>30 days), poor response to treatment and delayed diagnosis and/or treatment are associated with a poor outcome. Because the prevention of TMA in LDLT patients is difficult, early diagnosis and initiation of intensive therapies may be crucial to improve the prognosis.