Takanobu Shigeta

Biliary reconstruction in pediatric live donor liver transplantation: Duct-to-duct or Roux-en-Y hepaticojejunostomy

BACKGROUND Duct-to-duct biliary reconstruction (DD) is currently a standard procedure in adult live donor liver transplantation (LDLT). Its pediatric feasibility, however, has rarely been reported. The goal of this study is to assess the incidence and treatment of biliary complication after pediatric LDLT with DD or Roux-en-Y hepaticojejunostomy (RY). METHOD Sixty children received LDLT between November 2005 and June 2008, and their database was reviewed. RESULTS Biliary reconstruction was achieved with DD in 14 patients and with RY in 46 patients with mean follow-up period of 26.0 and 22.3 months, respectively. The incidence of biliary leakage in the DD and RY groups was 7.1% and 8.7%, respectively, and that of stricture was 28.6% and 10.9%, respectively; but the differences were not statistically significant. Biliary stricture in the DD group tended to require revision surgery with RY and longer treatment with percutaneous transhepatic cholangiodrainage compared with that in the RY group. CONCLUSION Theoretical advantages of DD over RY were not confirmed in this study. Duct-to-duct biliary reconstruction tended to encounter more biliary complications, especially stricture, with more difficulty in treating it than RY. Roux-en-Y hepaticojejunostomy seems preferable to DD in the setting of pediatric LDLT, but DD must be considered when making new Roux-en-Y limb seems impossible or troublesome owing to abdominal dense adhesion or short bowel syndrome.

Reducing the thickness of left lateral segment grafts in neonatal living donor liver transplantation

Liver transplantation is now an established treatment for children with end‐stage liver disease. Left lateral segment (LLS) grafts are most commonly used in split and living donor liver transplantation in children. In very small children, LLS grafts can be too large, and further nonanatomical reduction has recently been introduced to mitigate the problem of large‐for‐size grafts. However, the implantation of LLS grafts can be a problem in infants and very small children because of the thickness of the grafts, and these techniques do not address problems related to thickness. We herein describe a technique for reducing the thickness of living donor left lateral grafts and successful transplantation in a 2.8‐kg infant with acute liver failure. Liver Transpl 19:226–228, 2013.

Living donor liver transplantation for glycogen storage disease type Ib

Glycogen storage disease type 1b (GSD‐1b) is due to an autosomal recessive inborn error of carbohydrate metabolism caused by defects in glucose‐6‐phosphatase translocase. Patients with GSD‐1b have severe hypoglycemia with several clinical manifestations of hepatomegaly, obesity, a doll‐like face, and neutropenia. Liver transplantation has been indicated for severe glucose intolerance. This study retrospectively reviewed 4 children with a diagnosis of GSD‐1b who underwent living‐donor liver transplantation (LDLT). Between November 2005 and June 2008, 96 children underwent LDLT with overall patient and graft survival of 92.3%. Of these, 4 (4.2%) were indicated for GSD‐1b. All patients are doing well with an excellent quality of life because of the stabilization of glucose intolerance, decreased hospital admission, and normalized neutrophil count. LDLT appears to be a feasible option and is associated with a better quality of life for patients with GSD‐1b. Long‐term observation may be necessary to collect sufficient data to confirm the efficacy of this treatment modality. Liver Transpl 15:1867–1871, 2009.

The classification based on intrahepatic portal system for congenital portosystemic shunts

BACKGROUND/PURPOSE Liver transplantation was previously indicated as a curative operation for congenital absence of portal vein. Recent advances in radiological interventional techniques can precisely visualize the architecture of the intrahepatic portal system (IHPS). Therefore, the therapeutic approach for congenital portosystemic shunt (CPS) needs to be reevaluated from a viewpoint of radiological appearances. The aim of this study was to propose the IHPS classification which could explain the pathophysiological characteristics and play a complementary role of a therapeutic approach and management for CPS. METHODS Nineteen patients with CPS were retrospectively reviewed. The median age at diagnosis was 6.8 years old. Eighteen of these patients underwent angiography with a shunt occlusion test and were classified based of the severity of the hypoplasia of IHPS. RESULTS The eighteen cases who could undergo the shunt occlusion test were classified into mild (n=7), moderate (n=6) and severe types (n=5) according to the IHPS classification. The IHPS classification correlated with the portal venous pressure under shunt occlusion, the histopathological findings, postoperative portal venous flow and liver regeneration. Shunt closure resulted in dramatic improvement in the laboratory data and subclinical encephalopathy. Two patients with the severe type suffered from sepsis associated with portal hypertension after treatment, and from the portal flow steal phenomenon because of the development of unexpected collateral vessels. The patients with the severe type had a high risk of postoperative complications after shunt closure in one step, even if the PVP was relatively low during the shunt occlusion test. CONCLUSION The IHPS could be visualized by the shunt occlusion test. The IHPS classification reflected the clinicopathological features of CPS, and was useful to determine the therapeutic approach and management for CPS.

Impact of Rewarming Preservation by Continuous Machine Perfusion: Improved Post-Transplant Recovery in Pigs

BACKGROUND Utilization of grafts from donors after cardiac death (DCD) greatly expands the organ pool. However, implementation of such a strategy requires the development of novel preservation methods to achieve recovery from changes owing to warm ischemia. METHODS To assess potential methods, porcine livers harvested after 60 minutes of warm ischemic time (WIT) were perfused and preserved under the following conditions: Group 1 (n = 3), 2-hour simple cold storage and 2-hour machine perfusion (MP) at 8°C; group 2 (n = 3), 2 hours at 25°C and MP at 25°C and group 3 (n = 3), 2-hour simple cold storage and gradual rewarming to 25°C by MP. The preserved liver grafts were transplanted orthotopically into recipients. RESULTS The aspartate aminotransferase (AST), lactate dehydrogenase (LDH), and hyaluronic acid (HA) levels in recipient blood at 2 hours after reperfusion were significantly lower among group 3: AST, 789 ± 258.8, 1203 ± 217.0, and 421 ± 55.8 IU/L; LDH, 1417 ± 671.2, 2132 ± 483.9, and 634 ± 263.9 IU/L; and HA, 1660 ± 556.5, 1463 ± 332.3, and 575 ± 239.0 ng/mL for groups 1, 2 and 3, respectively. Histologically, necrosis and swelling of hepatocytes were less severe among group 3 than groups 1 and 2. Group 3 animals showed better vital responses and started spontaneous breathing within 2 hours after reperfusion; 1 recipient survived for >24 hours, although all animals in groups 1 and 2 died within 2 to 3 hours after reperfusion. CONCLUSION Rewarming by MP preservation may facilitate recovery and resuscitation of DCD liver grafts.

Living‐donor liver transplantation for propionic acidemia

Kasahara M, Sakamoto S, Kanazawa H, Karaki C, Kakiuchi T, Shigeta T, Fukuda A, Kosaki R, Nakazawa A, Ishige M, Nagao M, Shigematsu Y, Yorifuji T, Naiki Y, Horikawa R. Living‐donor liver transplantation for propionic acidemia.

Technical considerations of living donor hepatectomy of segment 2 grafts for infants

BACKGROUND The selection of an adequate graft to mitigate the problems associated with a large-for-size graft is essential to ensure the success of liver transplantation for smaller children. Reduced left lateral segment (LLS) grafts have been introduced to overcome this issue. METHODS Five infants underwent living donor liver transplantation (LDLT) with segment 2 grafts. In the preoperative assessment, the graft-to-recipient weight ratio (GRWR) and the ratio of the thickness of the donor LLS were used as a reference index for graft size matching, and a 3-dimensional (3D) computer-generated model of the donor liver was used for the analysis of the intrahepatic vasculature. During the donor operation, the relevant portal vein branches feeding to the reduced part of segment 3 were first exposed and divided, and then the parenchymal transection was performed. RESULTS Segment 2 grafts were selected in 3 cases and reduced segment 2 grafts were selected in the other 2 cases. The graft reduction was achieved with 46.6 ± 8.2% of the actual LLS, and thus the GRWR was reduced from 5.33 ± 2.09% to 2.70 ± 0.82%. The actual graft thickness was reduced by approximately half after the graft reduction. Primary abdominal closure was performed in all of the recipients. No surgical complications occurred in any of the donors or recipients. CONCLUSION A segment 2 graft could be a valuable option for graft type selection in LDLT for smaller children. Precise planning using a 3D computer-generated model of the donor liver and meticulous operative procedures are necessary to obtain a viable graft.

Liver transplantation for an infant with neonatal intrahepatic cholestasis caused by citrin deficiency using heterozygote living donor

Shigeta T, Kasahara M, Kimura T, Fukuda A, Sasaki K, Arai K, Nakagawa A, Nakagawa S, Kobayashi K, Soneda S, Kitagawa H. Liver transplantation for an infant with neonatal intrahepatic cholestasis caused by citrin deficiency using heterozygote living donor.
Pediatr Transplantation 2010: 14:E86–E88.

Effective control of Epstein–Barr virus infection following pediatric liver transplantation by monitoring of viral DNA load and lymphocyte surface markers

Imadome K‐I, Fukuda A, Kawano F, Imai Y, Ichikawa S, Mochizuki M, Shigeta T, Kakiuchi T, Sakamoto S, Kasahara M, Fujiwara S. Effective control of Epstein–Barr virus infection following pediatric liver transplantation by monitoring of viral DNA load and lymphocyte surface markers.

Living-donor liver transplantation with hyperreduced left lateral segment grafts: A single-center experience

Background In the setting of liver transplantation in small infants who receive left lateral segment (LLS) grafts, problems are encountered related to graft-size mismatching in the form of so-called “large-for-size” grafts. To address these problems, the feasibility of further reducing the size of LLS grafts to form hyperreduced LLS (HRLLS) grafts was investigated. Methods Of the 175 pediatric living-donor liver transplantations performed between November 2005 and December 2011 at our institute, 31 cases were performed using HRLLS grafts. The medical records were reviewed and data were collected retrospectively. Results The graft-to-recipient body weight ratio was successfully reduced from 5.2%±2.0% to 2.9%±0.5%. Portal vein thrombosis was observed in one case, and biliary stenosis was seen in two cases. No hepatic artery thrombosis was encountered. The graft and patient 2-year survival rate was 87%. When the results categorized according to the original disease were verified, patients with fulminant hepatic failure (FHF) weighed less and had smaller abdominal cavities compared with patients with cholestatic or metabolic disease. Patients with FHF frequently required skin or partial skin closure to avoid graft compression. For this reason, the anteroposterior diameters in the recipients’ abdominal cavities were not adequately large to accommodate the graft thickness, especially in patients with FHF. Conclusions In conclusion, living-donor liver transplantation using HRLLS grafts offers a safe and useful option for treating smaller infants.