Takanobu Hara

Intraoperative portal venous pressure and long‐term outcome after curative resection for hepatocellular carcinoma

Outcomes of liver resection for hepatocellular carcinoma (HCC) have improved owing to better surgical techniques and patient selection. Portal hypertension may influence outcome but the preoperative definition and role of portal hypertension are far from clear. The aim of this study was to elucidate the influence of portal venous pressure (PVP) measured directly during surgery on outcomes of liver resection in patients with HCC.

Standardized less invasive living donor hemihepatectomy using the hybrid method through a short upper midline incision.

BACKGROUND Recently, applications of less invasive liver surgery in living donor hepatectomy (LDH) have been reported. The objective of this study was to evaluate the safety and efficacy of a hybrid method with a midline incision for LDH. METHODS Hemihepatectomy using the hybrid method was performed in the fifteen most recent among 150 living donors who underwent surgery between 1997 and August 2011. Six donors underwent right hemihepatectomy and 9 underwent left hemihepatectomy. An 8-cm subxiphoid midline incision was created for hand assistance during liver mobilization and graft extraction. After sufficient mobilization of the liver, the hand-assist/extraction incision was extended to 12 cm for the right hemihepatectomy and 10 cm for a left hemihepatectomy. Encircling the hepatic veins and hilar dissection were performed under direct vision. Parenchymal transection was performed with the liver hanging maneuver. Bile duct division was performed after visualizing the planned transection point by encircling the bile duct using a radiopaque marker filament under real-time C-arm cholangiography. RESULTS All procedures were completed without any extra subcostal incision. All grafts were safely extracted through the 10-12-cm upper midline incision without mechanical injury. No donors required an allogeneic transfusion; all of them have returned to their preoperative activity levels. CONCLUSION LDH by the hybrid method with a short upper midline incision is a safe procedure.

Extended-criteria donors in liver transplantation Part II: reviewing the impact of extended-criteria donors on the complications and outcomes of liver transplantation

ABSTRACT Extended-criteria donors (ECDs) have an impact on early allograft dysfunction (EAD), biliary complications, relapse of hepatitis C virus (HCV), and survivals. Early allograft dysfunction was frequently seen in grafts with moderate and severe steatosis. Donors after cardiac death (DCD) have been associated with higher rates of graft failure and biliary complications compared to donors after brain death. Extended warm ischemia, reperfusion injury and endothelial activation trigger a cascade, leading to microvascular thrombosis, resulting in biliary necrosis, cholangitis, and graft failure. The risk of HCV recurrence increased by donor age, and associated with using moderately and severely steatotic grafts. With the administration of protease inhibitors sustained virological response was achieved in majority of the patients. Donor risk index and EC donor scores (DS) are reported to be useful, to assess the outcome. The 1-year survival rates were 87% and 40% respectively, for donors with a DS of 0 and 3. Graft survival was excellent up to a DS of 2, however a DS >2 should be avoided in higher-risk recipients. The 1, 3 and 5-year survival of DCD recipients was comparable to optimal donors. However ECDs had minor survival means of 85%, 78.6%, and 72.3%. The graft survival of split liver transplantation (SLT) was comparable to that of whole liver orthotopic liver transplantation. SLT was not regarded as an ECD factor in the MELD era any more. Full-right-full-left split liver transplantation has a significant advantage to extend the high quality donor pool. Hypothermic oxygenated machine perfusion can be applied clinically in DCD liver grafts. Feasibility and safety were confirmed. Reperfusion injury was also rare in machine perfused DCD livers.

Extended criteria donors in liver transplantation Part I: reviewing the impact of determining factors

ABSTRACT The definition and factors of extended criteria donors have already been set; however, details of the various opinions still differ in many respects. In this review, we summarize the impact of these factors and their clinical relevance. Elderly livers must not be allocated for hepatitis C virus (HCV) positives, or patients with acute liver failure. In cases of markedly increased serum transaminases, donor hemodynamics is an essential consideration. A prolonged hypotension of the donor does not always lead to an increase in post-transplantation graft loss if post-OLT care is proper. Hypernatremia of less than 160 mEq/L is not an absolute contraindication to accept a liver graft per se. The presence of steatosis is an independent and determinant risk factor for the outcome. The gold standard of the diagnosis is the biopsy. This is recommended in all doubtful cases. The use of HCV+ grafts for HCV+ recipients is comparable in outcome. The leading risk factor for HCV recurrence is the actual RNA positivity of the donor. The presence of a proper anti-HBs level seems to protect from de novo HBV infection. A favourable outcome can be expected if a donation after cardiac death liver is transplanted in a favourable condition, meaning, a warm ischemia time < 30 minutes, cold ischemia time < 8–10 hours, and donor age 50–60 years. The pathway of organ quality assessment is to obtain the most relevant information (e.g. biopsy), consider the co-existing donor risk factors and the reserve capacity of the recipient, and avoid further technical issues.

Self-assessment of postoperative scars in living liver donors.

The application of less invasive techniques for liver surgery in patients undergoing living donor hepatectomy (LDH) has been reported. The objective of this study was to evaluate physical status according to type of incision in donors.

Is a fluorescence navigation system with indocyanine green effective enough to detect liver malignancies

Although several reports have shown the efficacy of a fluorescence navigation system (FNS) with indocyanine green (ICG) to detect liver malignancies during hepatectomy, the real accuracy of this procedure is not yet clear. This study aimed to analyze the actual efficacy of ICG‐FNS in cirrhotic and non‐cirrhotic livers.

The Impact of Treated Bacterial Infections within One Month before Living Donor Liver Transplantation in Adults

BACKGROUND The impact of treated preoperative bacterial infections on the outcome of living-donor liver transplantation (LDLT) is not well defined. The aim of this study was to determine the frequency of pre-transplant bacterial infections within one month before LDLT and their impact on the post-transplant morbidity and mortality. MATERIAL AND METHODS We retrospectively reviewed the records of 50 adult LDLT recipients between January 2009 and October 2011. Patients were divided into two groups based on whether they had episodes of bacterial infections within one month before LDLT. RESULTS There were 20 patients who required antimicrobial therapy for pre-transplant infections. The pre-transplant infections comprised urinary tract infections (35%), cholangitis (10%), pneumonia (10%), bacteremia (5%), spontaneous bacterial peritonitis (5%), acute sinusitis (5%), subcutaneous abscess (5%), and empirical treatment (25%). Patients with pre-transplant infections had higher Child-Pugh scores [median, 11 vs. 9.5, P<0.05] and model for end-stage liver disease scores [median, 17.5 vs. 14, P<0.05] compared with the other patients. There were no correlations between the pathogens involved in the pre-transplant infections and those involved in post-transplant infections. The incidence of post-transplant infections was higher in the pre-transplant infection group within one week after LDLT, but was almost the same within one month after LDLT. The one-year survival rates were not significantly different between the groups. CONCLUSIONS Although pre-transplant infections are associated with a high risk of postoperative bacterial infection shortly after LDLT, they did not affect the short-term outcome when they had been appropriately treated before transplantation.

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 donor advocacy team: a risk management program for living organ, tissue, and cell transplant donors

AbstractBackground and PurposeAlthough the incidence of living donor death is low in Japan, statistics show one living liver donor death in more than 7000 living liver transplants. Thus, medical transplant personnel must recognize that the death of a living organ or tissue transplant donor can occur and develop an appropriate risk management program.Methods and resultsWe describe how Nagasaki University Hospital established and implemented a Donor Advocacy Team (DAT) program: a risk management program for initiation in the event of serious, persistent, or fatal impairment of an organ, tissue, or cell transplantation from a living donor.DiscussionThe purposes of the DAT program are as follows: 1.To disclose official information without delay.2.To provide physical and psychological care to the patient experiencing impairment and their family.3.To provide psychological care to the medical staff in charge of the transplant.4.To standardize the responses of the diagnosis and treatment department staff and other hospital staff.5.To minimize the damage that the whole medical transplantation system may suffer and leverage the occurrence for improvement. To address (1) and (5), actions, such as reporting and responses to the government, mass media, transplant-related societies, and organ transplant networks, have been established to ensure implementation.