Takayuki Takeichi

Magnet compression anastomosis for bile duct stenosis after duct‐to‐duct biliary reconstruction in living donor liver transplantation

A 44-year-old woman who had undergone living donor liver transplantation for fulminant hepatic failure presented obstructive jaundice 1 year after transplantation. A right lobe from her husband had been used for the original graft. Intraoperative cholangiography of the donor showed the bile duct of posterior inferior segment (B6) branching from the bile duct of anterior segment (Fig. 1). The bile duct of the donor was transected in the very short segment of the common trunk of the posterior and anterior branches of the right lobe. The orifice of the bile duct of the graft was single, but the shape of it was like the nose of a pig. This single orifice was anastomosed to the stump of the recipient’s common hepatic duct. A biliary stent tube (4-Frenchsized) was inserted into only the bile duct of the posterior segment. Coldand warm-ischemia time was 42 and 45 minutes, respectively. She initially recovered uneventfully in the early period after liver transplantation. The external stent tube was removed 3 months after the transplantation. Laboratory data at 11 months after the transplantation showed slight elevation of transaminases (aspartate aminotransferase: 80 IU/L, alanine aminotransferase: 100 IU/L) and total bilirubin (1.4 mg/dL). One month later, ultrasonography showed the dilated intrahepatic duct. Endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography disclosed the complete obstruction of the anterior branch (Fig. 2). The dilated duct was drained by the percutaneous transhepatic cholangiography drainage tube. Balloon dilatation was attempted though the percutaneous transhepatic cholangiography drainage tube, but it was

Living-related liver transplantation for type II citrullinemia using a graft from heterozygote donor.

BACKGROUND Type II citrullinemia (CTLN2) characterized by a liver-specific argininosuccinate synthetase deficiency is an adult onset genetical disorder caused by the mutation of SLC25A13 gene, which results in fulminant hyperammonemia often with poor prognosis. METHODS A 16-year-old Japanese boy presented fulminant hyperammonemia and encephalopathy and recovered after aggressive medical treatment. The patient was diagnosed as CTLN2 by plasma amino acid pattern and detection of the mutated SLC25A13 gene. We performed living-related liver transplantation (LRLT) using a graft from the genetically proven heterozygote father. RESULTS Serum amino acid concentration was normalized within a day after transplantation without protein restriction and medication. The patients postoperative course was natural. The patient is back in school 6 months after surgery. CONCLUSIONS Living-related liver transplantation using a graft from genetically proven heterozygote donors might be a permissible treatment modality for CTLN2. Long-term observation may be necessary to make a definite conclusion possible.

Intravital imaging of neutrophil recruitment in hepatic ischemia-reperfusion injury in mice.

Background Neutrophils are considered responsible for the pathophysiologic changes during hepatic ischemia-reperfusion (I/R) injury; however, few studies have examined real-time intravital neutrophil recruitment. Here, we show a method for imaging the neutrophil recruitment in hepatic I/R injury using two-photon laser scanning microscopy (TPLSM). Methods LysM-eGFP mice were subjected to 45 min of partial warm hepatic ischemia followed by reperfusion. Mice received an intravenous injection of tetramethylrhodamine isothiocyanate–labeled albumin to visualize the microvasculature. Using time-lapse TPLSM technique, we directly observed the behavior of neutrophils in I/R injury. Results At low magnification, four to six hepatic lobules could be visualized. The number of adherent neutrophils continued to increase for 4 hr after reperfusion, whereas their crawling velocity reached a maximum of 2 hr after reperfusion and then decreased gradually. High-magnification images revealed the presence or absence of blood circulation in sinusoids. Six hours after control operation or reperfusion, circulation was maintained in all sinusoids in the control group, whereas spotty nonperfused areas accompanied by neutrophil infiltration could be observed in the I/R group. Adherent neutrophils in perfused areas in the I/R group had more elongated shapes and moved more quickly than those in nonperfused areas and in the control group. Some hepatocytes affected by I/R injury showed the changes in their size and fluorescent intensity, which could attract neutrophils. Conclusions TPLSM was successfully used for intravital imaging of hepatic I/R injury in mice and has potential for a wide range of applications to investigate the mechanism of I/R injury.

Incidence and risk factors for new-onset diabetes in living-donor liver transplant recipients.

With the increased number of long‐term survivors after liver transplantation, new‐onset diabetes after transplantation (NODAT) is becoming more significant in patient follow‐up. However, the incidence of new‐onset diabetes after living‐donor liver transplantation (LDLT) has not been well elucidated. The aim of this study was to evaluate the incidence and risk factors for NODAT in adult LDLT recipients at a single center in Japan. A retrospective study was performed on 161 adult patients without diabetes who had been followed up for ≥three months after LDLT. NODAT was defined according to the 2003 American Diabetes Association/World Health Organization guidelines. The recipient‐, donor‐, operation‐, and immunosuppression‐associated risk factors for NODAT were assessed. Overall, the incidence of NODAT was 13.7% (22/161) with a mean follow‐up of 49.8 months. In a multivariate analysis, the identified risk factors for NODAT were donor liver‐to‐spleen (L‐S) ratio (hazard ratio [HR] = 0.022, 95% confidence interval [CI] = 0.001–0.500, p = 0.017), and steroid pulse therapy for acute rejection (HR = 3.320, 95% CI = 1.365–8.075, p = 0.008). In conclusion, donor L‐S ratio and steroid pulse therapy for acute rejection were independent predictors for NODAT in LDLT recipients. These findings can help in screening for NODAT and applying early interventions.

Biliary Reconstruction for Infantile Living Donor Liver Transplantation: Roux-en-Y Hepaticojejunostomy or Duct-to-Duct Choledochocholedochostomy?

Hepaticojejunostomy is a standard biliary reconstruction method for infantile living donor liver transplantation (LDLT), but choledochocholedochostomy for infants is not generally accepted yet. Ten pediatric recipients weighing no more than 10 kg underwent duct‐to‐duct choledochocholedochostomy (DD) for biliary reconstruction for LDLT. Patients were followed up for a median period of 26.8 months (range: 4.0–79.0 months). The incidence of posttransplant biliary complications for DD was compared with that for Roux‐en‐Y hepaticojejunostomy (RY). No DD patients and 1 RY patient (5%) developed biliary leakage (P > 0.05), and biliary stricture occurred in 1 DD patient (10%) and none of the RY patients (P > 0.05); none of the DD patients and 5 RY patients (25%) suffered from uncomplicated cholangitis after LDLT (P > 0.05), and 1 DD patient (10%) and 2 RY patients (10%) died of causes unrelated to biliary complications. In conclusion, both hepaticojejunostomy and choledochocholedochostomy resulted in satisfactory outcome in terms of biliary complications, including leakage and stricture, for recipients weighing no more than 10 kg. Liver Transpl 14:1761–1765, 2008.

Duct‐to‐duct biliary reconstruction in pediatric living donor liver transplantation

Abstract:  The results of duct‐to‐duct biliary reconstruction in six pediatric patients who received a living donor liver transplant aged from 2 months to 11 yr old are reported. The graft was either entire or a part of the left lateral segments. The orifice of the bile duct of the graft was anastomosed to the recipients’ hepatic duct in an end‐to‐end fashion by interrupted suture using 6–0 absorbable material. A transanastomotic external stent tube (4 Fr) was passed through the stump of the recipients’ cystic duct. Mean time for reconstruction was 24 min. All the recipients survived the operation and reinitiated oral intake on postoperative day 3. There were no early biliary complications. One 5‐yr‐old boy suffered from an anastomotic stenosis 9 months after transplantation. He underwent re‐anastomosis by Roux‐en Y (R‐Y) procedure and recovered uneventfully. Duct‐to‐duct anastomosis in pediatric living donor liver transplantation has benefits while the complication rate is comparable to R‐Y reconstruction.

Coefficient factor for graft weight estimation from preoperative computed tomography volumetry in living donor liver transplantation

In the clinical setting of living donor liver transplantation (LDLT), it is common to find a discrepancy between the graft volume estimated by preoperative computed tomography volumetry and the actual graft weight (AGW) measured on the back‐table. In this study, we attempt to find the coefficient factor that correlates the estimated graft volume to the AGW. Whole livers explanted in 25 LDLT recipients (17 cirrhotic and 8 morphologically normal with familial amyloid polyneuropathy) were evaluated to compare cirrhotic livers and noncirrhotic normal livers. In addition, right lobe grafts (n = 39) and left lobe grafts (n = 35) used in LDLTs were also evaluated to further determine the correlation between estimated graft volume and AGW. The correlation coefficient between estimated liver volume and actual liver weight was 1.01 in whole cirrhotic livers, whereas it was 0.85 in whole livers with familial amyloid polyneuropathy. In the partial liver grafts, it was 0.84 in right lobe grafts and 0.85 in left lobe grafts. In conclusion, we suggest that a correlation coefficient of 0.85 should be applied for the accurate calculation of the graft weight from the volume estimated by preoperative computed tomography in LDLT. Liver Transpl, 2011.

Bowel obstruction due to diaphragmatic hernia in an elder child after pediatric liver transplantation

Abstract:  A 10‐yr‐old boy with end‐stage liver cirrhosis due to Wilsons disease received a living donor liver transplantation (LDLT) at our institution. The donor was his father and the graft was a left lateral segment. The liver transplantation procedure and the postoperative course were uneventful. Two months after the procedure, he developed a first episode of bowel obstruction that was treated with conservative therapy. During a second episode of bowel obstruction, he also presented respiratory distress. A plain chest X‐ray revealed the presence of small intestine loops in the right thoracic cavity and bowel obstruction due to diaphragmatic hernia was diagnosed. Repair of the diaphragmatic hernia was performed and the patient has been doing well after the surgery. Diaphragmatic hernia after LDLT is rare but should be recognized as a possible complication when a left lobe or a left lateral segment graft is used.

Living domino liver transplantation in an adult with congenital absence of portal vein

Congenital absence of the portal vein (CAPV) is a rare malformation of the splanchnic venous system. Although CAPV is usually detected in the pediatric age group, our patient was a 35‐year‐old woman. She had been diagnosed with CAPV in 1996 when she was 27 years old. In 1998, she was placed on hemodialysis due to chronic renal failure. After several episodes of encephalopathy in 2002, liver transplantation (LT) was recommended to her and her family. Since there was no suitable living donor candidate, she was put on the waiting list for a deceased donor liver transplant in Japan. In 2004, her ammonia level increased to around 300 μg/dl, and she went into a coma lasting for three days. After recovering from this event, she underwent a living domino transplantation using a whole liver donated by a familial amyloid polyneuropathy (FAP) patient. Her portal vein, which had drained directly into the inferior vena cava (IVC), was transected together with a cuff of the IVC wall and anastomosed to the graft liver portal vein in an end‐to‐end fashion. In conclusion, liver transplantation proved to be a safe and effective way to save this patient and improve her quality of life. (Liver Transpl 2005;11:1285–1288.)

Comparative study: Vonoprazan and proton pump inhibitors in Helicobacter pylori eradication therapy

AIM To compare the effectiveness and safety of vonoprazan-based therapy with proton pump inhibitor (PPI)-based therapies to treat Helicobacter pylori (H. pylori). METHODS We retrospectively analysed data from first-line (vonoprazan or PPI with 200 mg clarithromycin and 750 mg amoxicillin twice daily for 7 d) (n = 1353) and second-line (vonoprazan or PPI with 250 mg metronidazole and 750 mg amoxicillin twice daily for 7 d) (n = 261) eradication treatments for H. pylori -positive patients with associated gastrointestinal diseases from April 2014 to December 2015 at Hattori Clinic, Japan. The primary endpoint was the eradication rate, which was assessed with a full analysis set. The secondary endpoints were adverse events and related factors. RESULTS After the first-line treatments, the eradication rates for vonoprazan, esomeprazol, rabeprazole, and lansoprazole were 87.9% (95%CI: 84.9%-90.5%), 71.6% (95%CI: 67.5%-75.5%), 62.9% (95%CI: 52.0%-72.9%), and 57.3% (95%CI: 50.4%-64.1%), respectively. The vonoprazan eradication rate was significantly higher than that of the PPIs (P < 0.01). Interestingly, smoking did not affect the H. pylori eradication rate in the vonoprazan group (P = 0.34), whereas it decreased the rates in the PPI groups (P = 0.013). The incidence of adverse events in the vonoprazan group was not different from the PPI group (P = 0.054), although the vonoprazan group exhibited a wider range of adverse events. Vonoprazan-based triple therapy was highly effective as a second-line treatment, with an eradication rate similar to that of PPI-based therapy. CONCLUSION Vonoprazan might be superior to PPIs in first-line H. pylori therapy, particularly for smokers. However, caution is required due to possible adverse events.