Shintaro Yagi

Impact of portal venous pressure on regeneration and graft damage after living‐donor liver transplantation

Several reports claim that portal hypertension after living‐donor liver transplantation (LDLT) adversely affects graft function, but few have assessed the impact of portal venous pressure (PVP) on graft regeneration. We divided 32 adult LDLT recipients based on mean PVP during the 1st 3 days after LDLT into a group with a PVP ≥ 20 mm of Hg (H Group; n = 17), and a group with a PVP < 20 mm of Hg (L Group; n = 15). Outcome in the H Group was poorer than in the L Group (58.8 vs. 92.9% at 1 year). Peak peripheral hepatocyte growth factor (HGF) during the 1st 2 weeks was higher in the H Group (L: 1,730 pg/mL, H: 3,696 pg/mL; P < .01), whereas peak portal vascular endothelial growth factor (VEGF) level during the 1st week was higher in the L Group (L: 433 pg/mL, H: 92 pg/mL; P < .05). Graft volume (GV) / standard liver volume (SLV) was higher in the H Group (L / H, at 2, 3, and 4 weeks, and at 3 months: 1.02 / 1.24, .916 / 1.16, .98 / 1.27, and .94 / 1.29, respectively; P < .05). Peak serum aspartate aminotransferase, bilirubin levels, and international normalized ratio after LDLT were significantly higher in the H Group, as was mean ascitic fluid volume. In conclusion, early postoperative PVP elevation to 20 mm of Hg or more was associated with rapid graft hypertrophy, higher peripheral blood HGF levels, and lower portal VEGF levels; and with a poor outcome, graft dysfunction with hyperbilirubinemia, coagulopathy, and severe ascites. Adequate liver regeneration requires an adequate increase in portal venous pressure and flow reflected by clearance of HGF and elevated VEGF levels. (Liver Transpl 2005;11:68–75.)

KICG value, a reliable real‐time estimator of graft function, accurately predicts outcomes in adult living‐donor liver transplantation

Reliable monitoring enabling evaluation of graft function is crucial after living‐donor liver transplantation (LDLT). A method to identify poor graft function at an early postoperative period would allow opportune intensive clinical management to bring about further improvements in LDLT outcomes. This study assessed the reliability of the indocyanine green (ICG) elimination rate constant (KICG) value as an estimator of graft function and determined the actual temporal changes of KICG after LDLT. KICG values were measured using a noninvasive method in 30 adult recipients up to 28 days after LDLT. The receptor index (LHL15) based on liver scintigraphy, and graft parenchymal damage score based on histopathological findings were evaluated after LDLT and correlated well with simultaneous KICG. Thus, KICG measured by noninvasive method was confirmed as accurately evaluating graft function. Changes of KICG after LDLT in recipients with good graft function were maintained, after some falls in the early periods, and had a significant difference compared with those for recipients without good graft function; moreover, there were already significant differences in KICG 24 hours after LDLT. Mean transit time reflecting systemic hemodynamics revealed that recipients without good outcomes fell into an unstable systemic hemodynamic state, and effective hepatic blood flow has a large influence on liver regeneration after LDLT. In conclusion, we suggested that KICG values can predict clinical outcomes at the early postoperative period after LDLT by sharply reflecting the influence of systemic dynamics on splanchnic circulation. Liver Transpl 12:605–613, 2006.

Splenectomy does not offer immunological benefits in ABO-incompatible liver transplantation with a preoperative rituximab.

Background. Preformed anti-ABO antibodies are primarily responsible for antibody-mediated rejection (AMR) after ABO-incompatible (ABO-I) liver transplantation (LT) resulting in lethal hepatic necrosis and biliary complications. Splenectomy, an integral part of protocol for ABO-I LT, decreases anti-ABO antibodies. With the preoperative rituximab prophylaxis, role of the splenectomy for ABO-I LT is now under debate. We investigated the necessity of splenectomy by retrospective analyses of the short-term anti-ABO antibody response and long-term outcomes of ABO-I LT. Methods. Thirty-seven ABO-I LTs performed from May 2006 through July 2009, at Kyoto University Hospital, Kyoto, Japan, were retrospectively analyzed. Twenty-seven patients who underwent splenectomy (splenectomy group) received 329.6±35.8 mg rituximab 17.7±11.9 days before living donor LT. Ten patients without splenectomy (nonsplenectomy group) received 320.0±10.3 mg rituximab 26.6±21.3 days before transplantation. All patients received a posttransplant hepatic artery infusion with prostaglandin E1 and methylprednisolone. Perioperative anti-ABO immunoglobulin M and immunoglobulin G antibody titers, rejections, biliary complications, infections, and survival results were compared. Results. Preoperative rituximab with plasma exchange effectively reduced anti-ABO antibodies in both patient groups at the time of LT. There was no statistically significant difference observed in anti-ABO immunoglobulin M and immunoglobulin G antibody titers between the “splenectomy” and “nonsplenectomy” groups during the initial 8 weeks. The clinical outcomes, including AMR, biliary complications, infections, and survival, were similar in both the groups. Conclusions. Preoperative rituximab effectively decreased the anti-ABO antibodies sufficiently to prevent the AMR irrespective of splenectomy. Splenectomy does not offer any immunological benefit in ABO-I LT with preoperative rituximab.

Impact of venous drainage on regeneration of the anterior segment of right living‐related liver grafts

Abstract:u2002 The effect of additional venous reconstruction on morphologic and functional regeneration of the anterior segment of right‐lobe liver grafts was compared among three groups according to graft type: right liver graft without the middle hepatic vein (MHV) or MHV tributaries (nu2003=u20037), with MHV tributaries (nu2003=u200325) and with the MHV (nu2003=u200310). Whole graft volume (GV) and anterior segment volume (ASV) were estimated from CT scans and post‐operative laboratory data and daily ascitic fluid volume were examined. Peak GV in each group was reached two or three wk after surgery. The ASV/GV ratios of the grafts with the MHV or MHV tributaries were higher than those of grafts without additional venous reconstruction. However, the asparate aminotransferase and ascitic fluid volume values in the group that received grafts with MHV tributaries were higher than in the group that received grafts with the MHV in the same period. Although rapid enlargement of the anterior segment of right‐lobe grafts with MHV tributaries occurred in the early post‐operative period, complete functional liver regeneration may not occur even after additional tributary reconstruction. These results suggest that the selection of right‐lobe grafts with the MHV is more beneficial for recipients, as long as donor safety is protected and that as many MHV tributaries as possible should be reconstructed in right‐lobe grafts without MHV.

Maximizing venous outflow after right hepatic living donor liver transplantation with a venous graft patch.

Between March 2002 and September 2004, 36 patients at Mie University Hospital underwent living donor liver transplantation (LDLT) of a right lobe graft without the middle hepatic vein. The patients were divided into two groups: group I (n = 25) received ordinary hepatic vein anastomoses, and group II (n = 11) received a venous graft patch in the subsequent procedure. Between groups, we compared hepatic vein blood flow (ultrasound), liver volume (CT scan), laboratory data, and ascitic fluid volume. Outflow block developed as a complication in 1 patient in group I. Hepatic vein blood flow on postoperative day (POD) 3 was significantly better in group II, and hepatic vein waveforms of most group II patients showed the triphasic pattern, especially on PODs 3 and 5. The total bilirubin and aspartate aminotransferase values on POD 1 were significantly better in group II, and daily ascitic fluid volume on PODs 3 and 5 was significantly lower in group II. Thus, modified venoplasty with a graft patch in the right hepatic LDLT not only improved hepatic vein hemodynamics (based on the ultrasound findings), but also improved liver function and decreased daily ascitic fluid volume.

Noradrenalin-Secreting Retroperitoneal Schwannoma Resected by Hand-Assisted Laparoscopic Surgery: Report of a Case

A 66-year-old woman was admitted to our hospital for investigation of a retroperitoneal mass. She was asymptomatic but her serum noradrenalin and vanillylmandellic acid levels were increased remarkably. Computed tomographic angiography showed a mass in the left side of the superior mesenteric artery (SMA) divergence, 6 × 4u2009cm in size, supplied mainly by the left adrenal artery. We performed hand-assisted laparoscopic surgery (HALS) using a Cavitron ultrasonic surgical aspirator. Abdominal exploration revealed that the tumor was located in the left side of the SMA root, but was not adhered to the adjacent organs. Her vital signs remained stable during the operation. Microscopic examination revealed a palisade formation, confirming a histopathological diagnosis of degenerated schwannoma (Antoni type B). Immunohistologically, the tumor cells were stained with S-100 protein and neuron-specific enolase. Her noradrenalin level normalized immediately after the operation and she remains in good health 3 years 2 months later.

Characteristics of Nutritional Status and the Effect of Pre-transplant Branched-chain Amino Acid Administration in Patients Undergoing Living Donor Liver Transplantation

Background: Protein-energy malnutrition is common in patients with end-stage liver disease undergoing liver transplantation. We examined the characteristics of nutritional status and impact of pre-admission branched-chainamino- acids treatment on skeletal muscle mass, nutritional/metabolic parameters and on post-transplant outcomes. Methodology: Preoperative skeletal muscle mass and nutritional/metabolic parameter levels were compared in 129 patients undergoing adult-to-adult living donor liver transplantation whether received branched-chain-aminoacids treatment before admission or not. We examined relationships among these parameters, and risk factors for post-transplant bacteremia and early mortality after LT focusing on nutritional parameters. Results: Pre-albumin and branched-chain-amino-acids-to-tyrosine ratio were significantly higher while tyrosine was lower in branched-chain-amino-acids-pre-supplemented than non-pre-supplemented group, while skeletal muscle mass, total lymphocyte count, zinc, branched-chain-amino-acids and ammonia levels were not significantly different. Skeletal muscle mass positively correlated with tyrosine (r=0.437, P<0.001) and branched-chain-aminoacids (r=0.282, P=0.001) and negatively with branched-chain-amino-acids-to-tyrosine-ratio (r=-0.259, P=0.003). Multivariate predictors of post-transplant bacteremia were: Child-Pugh class C (P=0.012), low preoperative total lymphocyte count (P=0.027), operative blood loss ≥ 10 L (P=0.039) and absence of pre-admission branched-chainamino- acids treatment (P=0.040). Nutritional/metabolic parameters and pre-admission branched-chain-amino-acids treatment were not crucial for post-transplant early mortality. Conclusion: Pre-admission branched-chain-amino-acid therapy could ameliorate preoperative amino acid imbalance and the incidence of post-transplant bacteremia.

A Rare Variation of the Biliary Tree of Relevance to Live Liver Donation

An appreciation of the potential anatomical variations of the vascular and biliary systems is essential for donor safety in the context of live donor hepatectomy (1,2). We previously reported that variant biliary anatomy was present in a substantial proportion of donors with trifurcated portal veins (2,3). The present report describes two rare cases of biliary anomaly with an independent bifurcation of a branch of segment 2 (B2) from the anterior or posterior bile duct.