Shugo Mizuno

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.

Donor outcome and liver regeneration after right-lobe graft donation.

Sufficiently detailed information on donor safety and the liver regeneration process following right‐lobe living donation has been unavailable, so we evaluated donor outcome and liver regeneration in 13 males and 14 females (39.0 ± 14.8 years old) who provided 27 right‐lobe grafts without the middle hepatic vein. Preoperative total liver volume (TLV), graft volume, and postoperative changes in residual liver volume (RLV) were measured by volumetric computed tomography. Histological steatosis of the liver was graded as none, minimal (≤10%), and mild (11–30%). The median follow‐up period was 337 days. Estimated graft volume and actual graft weight were linearly correlated (Y = 177.85 + 0.795X, R2 = 0.812, P < 0.0001). Graft‐to‐recipient weight ratio was 1.08 ± 0.19%. Four donors had postoperative complications, but they resolved in response to conservative treatment. Postoperative hospital stay was 15.2 ± 5.5 days. Peak liver enzyme values were significantly higher in donors with mild steatosis (n = 7) than without steatosis (n = 16) (P < 0.05). Donor RLV was 40.8 ± 6.6% of original TLV at surgery, 79.8 ± 12.0% by 6 months, and 97.2 ± 10.8% by 12 months. At 3 months the liver of the older donors (≥50 years) had grown significantly more slowly than in younger donors (70.4 ± 9.2% vs. 79.3 ± 9.6%, P = 0.0391). In conclusion, right hepatectomy without middle hepatic vein of living donors is a safe procedure with acceptable morbidity, and the residual liver regenerated to its preoperative size by 1 year. However, meticulous care should be taken in donors with liver steatosis and aged donors.

Experiences and problems pre-operative anti-CD20 monoclonal antibody infusion therapy with splenectomy and plasma exchange for ABO-incompatible living-donor liver transplantation.

Abstract:  Background:  ABO‐incompatible living‐donor liver transplantation (LDLT) requires a reduction of the anti‐ABO antibody titer to <16 before transplantation, which is usually achieved by pre‐operative plasma exchange (PE) or double‐filtration plasmapheresis. ABO‐incompatible transplantations have been performed after a splenectomy with heavy drug immunosupression plus B‐cell‐specific drugs. Here, we evaluated a pre‐transplantation infusion protocol with an anti‐CD20 monoclonal antibody (rituximab) for ABO‐incompatible LDLT.

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

Abstract:  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 (n = 7), with MHV tributaries (n = 25) and with the MHV (n = 10). 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.

Laparoscopic Spleen-Preserving Pancreatic Tail Resection for an Intrapancreatic Accessory Spleen Mimicking a Nonfunctioning Endocrine Tumor: Report of a Case

Laparoscopic surgery is now performed for several pancreatic disorders, such as benign tumors of the pancreatic body or tail, which are a good indication for laparoscopic resection. However, the risk of pancreatic fistula after distal pancreatectomy, performed laparoscopically or by open surgery, is a topic of debate. We report the case of a 61-year-old man in whom a routine follow-up computed tomography (CT) scan showed a solid, well-defined mass, 1.5 cm in diameter, in the pancreatic tail. The mass was homogeneously enhanced from the early phase to the super-delayed phase on enhanced CT. We suspected a nonfunctioning endocrine tumor of the pancreas, and surgery was performed laparoscopically. After dissecting the pancreatic tail away from the splenic hilum and the splenic vessels, it was resected using only a linear stapler. The histological diagnosis was an intrapancreatic accessory spleen. The patient was discharged on postoperative day 14, but was readmitted 6 days later because of a pancreatic fistula, which was treated by CT-guided percutaneous drainage.

Indocyanine Green (ICG) Fluorescence Imaging-Guided Cholangiography for Donor Hepatectomy in Living Donor Liver Transplantation

We read with great interest the paper by Guba et al. reporting intraoperative ‘no go’ donor hepatectomies in living donor liver transplantation (LDLT) (1). The authors reported that unusual anatomies of the biliary systems were the most common reason for ‘no go’ hepatectomies. Actually, the aberrant hepatic duct around the hepatic hilum was reported as 15% and the posterior branch of the right hepatic duct directly came from left hepatic duct in 6% in examination of 100 cadavers (2). In fact, in LDLT, biliary complication in donor operation is well known to be most common (3), and also appropriate cutting line of the bile duct of the graft liver is the most important for preventing biliary complications of both donors and recipients.

Survival rates according to the Cancer of the Liver Italian Program scores of 345 hepatocellular carcinoma patients after multimodality treatments during a 10-year period in a retrospective study.

Background and Aim:  The Cancer of the Liver Italian Program (CLIP) score has been demonstrated to have superior prognostic ability in hepatocellular carcinoma (HCC) patients worldwide, but there has never been sufficient assessment of the efficacy of treatment modalities according to the CLIP score. This retrospective cohort study of HCC patients was conducted to assess the efficacy of treatment modalities according to the CLIP score.

Intrahepatic Hepatic Vein Stenosis After Living‐Related Liver Transplantation Treated by Insertion of an Expandable Metallic Stent

Although the incidence of stenosis and obstruction of the hepatic venous anastomosis after right hepatic living‐related liver transplantation (LRLT) has been found to be higher than after orthotopic liver transplantation (OLT), to the best of our knowledge, intrahepatic stenosis of the venous trunk in the early period after right hepatic LRLT has never been reported in the literature. A 53‐year‐old man who underwent right hepatic LRLT, postoperatively, developed liver dysfunction and an increasing amount of ascites, and a Doppler sonogram showed a flat waveform and low‐flow velocity in the hepatic vein. Based on these findings an outflow block was suspected, and a hepatic venogram and manometry revealed intrahepatic stenosis of a tortuous hepatic venous trunk and a pressure gradient of 14 mmHg at the site of the stenosis. We inserted an expandable metallic stent (EMS) at the site of intrahepatic venous stenosis, and its insertion was followed by a decrease in pressure gradient. Liver function recovered, and the volume of ascitic fluid decreased after placement of the EMS. The results of an analysis of the venogram and CT volumetric data suggested that the pathogenesis of the stenosis was twisting of the venous trunk during hypertrophy of the liver parenchyma.

Paradoxical impact of the remnant pancreatic volume and infectious complications on the development of nonalcoholic fatty liver disease after pancreaticoduodenectomy

The aim of the present study was to evaluate perioperative risk factors for development of nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD), paying special attention to remnant pancreatic volume (RPV) and postoperative infection.