Satomi Okada

Analysis of early relaparotomy following living donor liver transplantation

We retrospectively analyzed the causes, risk factors, and impact of early relaparotomy after adult‐to‐adult living donor liver transplantation (LDLT) on the posttransplant outcome. Adult recipients who underwent initial LDLT at our institution between August 1997 and August 2015 (n = 196) were included. Any patients who required early retransplantation were excluded. Early relaparotomy was defined as surgical treatment within 30 days after LDLT. Relaparotomy was performed 66 times in 52 recipients (a maximum of 4 times in 1 patient). The reasons for relaparotomy comprised postoperative bleeding (39.4%), vascular complications (27.3%), suspicion of abdominal sepsis or bile leakage (25.8%), and others (7.6%). A multivariate analysis revealed that previous upper abdominal surgery and prolonged operative time were independent risk factors for early relaparotomy. The overall survival rate in the relaparotomy group was worse than that in the nonrelaparotomy group (6 months, 67.3% versus 90.1%, P < 0.001; 1 year, 67.3% versus 88.6%, P < 0.001; and 5 years, 62.6% versus 70.6%, P = 0.06). The outcome of patients who underwent 2 or more relaparotomies was worse compared with patients who underwent only 1 relaparotomy. In a subgroup analysis according to the cause of initial relaparotomy, the survival rate of the postoperative bleeding group was comparable with the nonrelaparotomy group (P = 0.96). On the other hand, the survival rate of the vascular complication group was significantly worse than that of the nonrelaparotomy group (P = 0.001). Previous upper abdominal surgery is a risk factor for early relaparotomy after LDLT. A favorable longterm outcome is expected in patients who undergo early relaparotomy due to postoperative bleeding. Liver Transplantation 22 1519–1525 2016 AASLD.

A Donor Age-based and Graft Volume–based Analysis for Living Donor Liver Transplantation in Elderly Recipients

Background Given the expected increase in the number of elderly recipients, details regarding how clinical factors influence the outcome in living donor liver transplantation (LDLT) for the elderly remain unclear. We examined the survival outcomes according to the results of donor age-based and graft volume–based analyses and assessed the impact of prognostic factors on the survival after LDLT for elderly recipients. Methods The 198 adult recipients were classified into 2 groups: an elderly group (n = 70, E group; ≥ 60 years of age) and a younger group (n = 128, Y group; <60 years of age). We analyzed the prognostic factors for the survival in the E group and the survival rate for both groups at several follow-up points and conducted subgroup analyses in the E group by combining the donor age (≥50 vs <50 years) and graft weight (GW)/standard liver volume (SLV) (≥40% vs <40%). Results Donor age (hazard ratio [HR], 2.17; P = 0.062) and GW/SLV (HR, 1.80; P = 0.23) tended to have a high HR in the E group. The overall patient survival rates at 1, 3, and 5 years were 78.3%, 73.0%, and 61.0% in the E group, and 82.0%, 75.1%, and 69.2% in the Y group, respectively (P = 0.459). However, the outcomes tended to be worse in recipients of grafts from donors ≥50 years of age than in those with grafts from younger donors with GW/SLV < 40% (P = 0.048). Conclusions A worse outcome might be associated with aging of the donor, which leads to impairment of the graft function and liver regeneration. Both the graft volume and donor age should be considered when choosing grafts for LDLT in elderly patients.

The Kupffer Cell Number Affects the Outcome of Living Donor Liver Transplantation from Elderly Donors

Background There have been no previous reports how Kupffer cells affect the outcome of living donor liver transplantation (LDLT) with an elderly donor. The aim of this study was to elucidate the influence of Kupffer cells on LDLT. Methods A total of 161 adult recipients underwent LDLT. The graft survival, prognostic factors for survival, and graft failure after LDLT were examined between cases with a young donor (<50, n = 112) and an elderly donor (≥50, N = 49). The Kupffer cells, represented by CD68-positive cell in the graft, were examined in the young and elderly donors. Results In a multivariable analysis, a donor older than 50 years, sepsis, and diabetes mellitus were significant predictors of graft failure after LDLT. The CD68 in younger donors was significantly more expressed than that in elderly donors. The group with a less number of CD68-positive cells in the graft had a significantly poor survival in the elderly donor group and prognostic factor for graft failure. Conclusions The worse outcome of LDLT with elderly donors might be related to the lower number of Kupffer cells in the graft, which can lead to impaired recovery of the liver function and may predispose patients to infectious diseases after LDLT.

Clinical Evaluation of Hepatic Portal Venous Gas after Abdominal Surgery

Hepatic portal venous gas (HPVG) is induced by various abdominal diseases. Since HPVG is accompanied by bowel ischemia, intestinal infection and hypovolemia, various modes of critical management are needed to treat the underlying conditions. HPVG associated with abdominal complications after surgery has rarely been reported. We present 4 patients with HPVG after abdominal surgery: 2 of the 4 patients died of multiple organ failure, and the other 2 recovered with solely conservative therapy. Although postoperative HPVG is a severe and life-threatening condition, early detection and systemic treatment lead to a better patient outcome.

Standardized hybrid living donor hemihepatectomy in adult‐to‐adult living donor liver transplantation

The aim of this study was to analyze the outcomes of the most updated version and largest group of our standardized hybrid (laparoscopic mobilization and hepatectomy through midline incision) living donor (LD) hemihepatectomy compared with those from a conventional laparotomy in adult‐to‐adult living donor liver transplantation (LDLT). Of 237 adult‐to‐adult LDLTs from August 1997 to March 2017, 110 LDs underwent the hybrid procedure. Preoperative and operative factors were analyzed and compared with conventional laparotomy (n = 126). The median duration of laparoscopic usage was 26 minutes in the hybrid group. Although there was improvement in applying this procedure over time from the beginning of the series of cases studied, blood loss and operative duration were still smaller and shorter in the hybrid group. There was no significant difference between the groups in the incidence of postoperative complications greater than or equal to Clavien‐Dindo class III. There was no difference in recipient outcome between the groups. Our standardized procedure of hybrid LD hepatectomy is applicable and safe for all types of LD hepatectomies, and it enables the benefit of both the laparoscopic and the open approach in a transplant center without a laparoscopic expert. Liver Transplantation 24 363–368 2018 AASLD.

Aspartate transaminase–platelet ratio and Fibrosis-4 indices as effective markers for monitoring esophageal varices in HIV/hepatitis C virus co-infected patients due to contaminated blood products for hemophilia

We examined the feasibility of the aspartate transaminase (AST)–platelet ratio index (APRI) and Fibrosis‐4 (FIB4) score, which are well‐established markers for liver fibrosis, as indicators for monitoring esophageal varices in patients who were co‐infected with HIV and hepatitis C virus (HCV) due to contaminated blood products for hemophilia in Japan.

APRI and FIB4 as effective markers for monitoring esophageal varices in HIV/HCV co-infected patients due to contaminated blood products for hemophilia.

We examined the feasibility of the aspartate transaminase (AST)–platelet ratio index (APRI) and Fibrosis‐4 (FIB4) score, which are well‐established markers for liver fibrosis, as indicators for monitoring esophageal varices in patients who were co‐infected with HIV and hepatitis C virus (HCV) due to contaminated blood products for hemophilia in Japan.

Surgical findings and technical knacks to performing living donor liver transplantation for hepatocellular carcinoma recurrence after carbon ion radiotherapy

Abstract Although carbon-ion radiotherapy (CIRT) has been reported to achieve good local control of hepatocellular carcinoma (HCC), liver transplantation is still required in patients with tumor recurrence. However, few cases of living donor liver transplantation (LDLT) after curative CIRT for HCC has been reported. It would be of great interest to ascertain the true situation of the irradiated region as well as to clarify the surgical points. We herein report the surgical findings and our experience along with technical difficulties and knacks concerning two cases of LDLT for HCC after CIRT. Both patients suffered tumor recurrence after curative CIRT for HCC. Severe adhesions were found between the irradiated region and the surrounding tissues, which resulted in surgical difficulties. Histological findings showed severe tissue fibrosis in the CIRT area. We should pay attention to adhesions in the irradiated area caused by CIRT including the vascular reconstruction during surgery.

A Predictive Formula for Portal Venous Pressure Prior to Liver Resection Using Directly Measured Values

ABSTRACT Purpose: Despite refinements in surgical techniques for liver resection, evaluation of hepatic reserve disparity remains one of the most common problems in liver surgery, especially for hepatic malignancies such as hepatocellular carcinoma (HCC). Portal venous pressure (PVP) is regarded one of the important factors in selecting treatment strategy, although its measurement can be invasive and complex. Methods: To establish a formula for calculating PVP preoperatively, intraoperative directly measured PVP was used in 177 patients with preoperative factors and liver function tests such as age, sex, virus status, platelet count, prothrombin time, albumin, total bilirubin, alanine aminotransferase (ALT), Child–Pugh grade, liver damage defined by the Liver Cancer Study Group of Japan, indocyanine green retention rate at 15 min (ICG-R15), and the aspartate transaminase (AST)-platelet ratio index (APRI). Results: Although 90% of the patients were classified as Child-Pugh A, median direct PVP was 16.5 cm H2O (5.5–37.0) and the percentage of PVP greater than 20 cm H2O was 27.1%, reflecting portal hypertension due to liver damage. After multiple regression analysis, the formula PVP (cmH2O) = EXP[2.606 + 0.01 × (ICG-R15) + 0.015 × APRI] was established from the measured data. Conclusion: Considering its simplicity of use, we have adopted this formula for predicting PVP in determining treatment strategy for HCC and other hepatic malignancies.

Pretransplant serum procalcitonin level for prediction of early post-transplant sepsis in living donor liver transplantation: Prediction of post-transplant sepsis

Infection is a frequent cause of in‐hospital mortality after liver transplantation (LT). Elimination of possible risks in the pretransplant period, early diagnosis of post‐transplant sepsis, and prompt treatment with antimicrobial agents are important. The objectives of this study were to analyze the impact of early post‐transplant sepsis on outcomes and to clarify the value of predictive factors for early post‐transplant sepsis.