Toshihiro Kitajima

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.

Left lobe graft poses a potential risk of hepatic venous outflow obstruction in adult living donor liver transplantation

Hepatic venous outflow obstruction (HVOO) is a critical complication after living donor liver transplantation (LDLT). This study aimed to evaluate the incidence of HVOO and the risk factors for HVOO in adults. From 2005 to 2015, 430 adult LDLT patients (right lobe [RL] graft, 270 patients; left lobe [LL] graft, 160 patients) were enrolled and divided into no HVOO (n = 413) and HVOO (n = 17) groups. Patient demographics and surgical data were compared, and risk factors for HVOO were analyzed. Furthermore, the longterm outcomes of percutaneous interventions as treatment for HVOO were assessed. HVOO occurred in 17 (4.0%) patients. The incidence of HVOO in patients receiving a LL graft was significantly higher than in those receiving a RL graft (8.1% versus 1.5%; P = 0.001). The body weight and caliber of hepatic vein anastomosis in the HVOO group were significantly lower compared with the no HVOO group (P = 0.02 and P = 0.008, respectively). Multivariate analysis revealed that only LL graft was an independent risk factor for HVOO (OR, 4.782; 95% CI, 1.387‐16.488; P = 0.01). Among 17 patients with HVOO, 7 patients were treated with single balloon angioplasty, and 9 patients who developed recurrence were treated with repeated interventions. Overall, 6 patients underwent stent placement: 1 at the initial procedure, 3 at the second procedure for early recurrence, and 2 following repeated balloon angioplasty (≥3 interventions). These 6 patients experienced no recurrence. Overall graft survival was not significantly different between the HVOO and no HVOO groups (P = 0.99). In conclusion, the use of a LL graft was associated with HVOO, and percutaneous interventions were effective for treating adult HVOO after LDLT. Liver Transplantation 22 785–795 2016 AASLD.

Living donor liver transplantation during the first 3 months of life

Living donor liver transplantation (LDLT) is now an established technique for treating children with end‐stage liver disease. Few data exist about liver transplantation (LT) for exclusively young infants, especially infants of <3 months of age. We report our single‐center experience with 12 patients in which LDLT was performed during the first 3 months of life and compare the results with those of older infants who underwent LT. All of the patients were treated at the National Center of Child Health and Development, Tokyo, Japan. Between November 2005 to November 2016, 436 children underwent LT. Twelve of these patients underwent LT in the first 3 months of life (median age, 41 days; median weight, 4.0 kg). The indications for transplantation were fulminant hepatic failure (n = 11) and metabolic liver disease (n = 1). All the patients received the left lateral segment (LLS) in situ to mitigate the problem of graft‐to‐recipient size discrepancy. A reduced LLS graft was used in 11 patients and a segment 2 monosegment graft was used in 1 patient. We compared the results with those of infants who were 4‐6 months of age (n = 67) and 7‐12 months of age (n = 110) who were treated in the same study period. There were significant differences in the Pediatric End‐Stage Liver Disease score and the conversion rate of tacrolimus to cyclosporine in younger infants. Furthermore, the incidence of biliary complications, bloodstream infection, and cytomegalovirus infection tended to be higher, whereas the incidence of acute cellular rejection tended to be lower in younger infants. The overall cumulative 10‐year patient and graft survival rates in recipients of <3 months of age were both 90.9%. LDLT during the first 3 months of life appears to be a feasible option with excellent patient and graft survival. Liver Transplantation 23 1051–1057 2017 AASLD.

Living donor liver transplantation with alternative porto-left gastric vein anastomosis in patients with post-Kasai extrahepatic portal vein obstruction.

EPVO is a common cause of prehepatic portal hypertension in pediatric patients and sometimes results in cavernous transformation of the PV. We herein present the cases of two patients who underwent LDLT for EPVO with post‐Kasai biliary atresia. PV reconstruction was performed with a porto‐left gastric vein anastomosis. The patient who underwent PV reconstruction using an interposition vein graft is doing well without surgical complications, whereas PV anastomotic stenosis was detected three months after LDLT in the patient who did not receive an interposition vein graft. The availability of vein grafts is limited in the LDLT setting. In such cases, performing PV reconstruction with varicose veins using interposition vein grafts is a feasible and valuable alternative option for obtaining a sufficient portal blood flow. Our experiences suggest that using interposition vein grafts may be appropriate for preventing the anastomotic stenosis caused by the fragility of varicose veins.

Prevention of transient liver damage after laparoscopic gastrectomy via modification of the liver retraction technique using the Nathanson liver retractor

Although laparoscopic radical gastrectomy has several advantages over conventional surgery, postoperative liver dysfunction is an unwanted complication. The major cause is considered to be use of mechanical liver retraction. To prevent liver damage after laparoscopic gastrectomy, we modified the liver retraction method: the retractor was used only after lymph node dissection along the greater curvature had been completed, and it was released before reconstruction and intermittent repositioning to avoid discoloration of the liver parenchyma. This study sought to determine whether postoperative liver dysfunction could be prevented by making these simple modifications.

A novel technique for collateral interruption to maximize portal venous flow in pediatric liver transplantation

Portal vein (PV) reconstruction is a key component for success in pediatric liver transplantation (LT). Biliary atresia (BA) often causes the native PV to become sclerotic or hypoplastic, and the portal venous flow (PVF) may decrease, whereas the collateral vessels develop and provoke a further decrease in the PVF. This negative spiral in PV circulation can complicate PV reconstruction at the time of LT. There have been several technical refinements reported in previous studies, including vein graft interposition and longitudinal venoplasty. However, aside from the techniques of PV reconstruction, collateral interruption and sufficient PVF are crucial issues that can affect the initial graft function. At the end of April 2016, we had performed 403 LTs in 389 recipients (living donor liver transplantation [LDLT], n 5 379; deceased donor LT, n 5 20; domino LT, n 5 4). PV complications occurred after LT in 23 (5.7%) patients, including PV thrombus in 4 (1.0%) and PV stricture in 19 (4.7%). Notably, 18 (4.5%) patients required reanastomosis due to intraoperative PV thrombosis, which occurred after primary PV reconstruction. Intraoperative PV thrombosis might occur due to insufficient PVF with incomplete interruption of the collaterals or inappropriate decision making with regard to the technique of PV reconstruction, especially the use of the sclerotic native PV without any technical modifications.

Intraoperative fluorescent cholangiography using indocyanine green for laparoscopic fenestration of nonparasitic huge liver cysts.

Bile duct injury is one of the known serious complications of laparoscopic fenestration for nonparasitic liver cysts. Herein, we report the case of a huge liver cyst for which we performed laparoscopic fenestration using intraoperative fluorescent cholangiography with indocyanine green. A 71‐year‐old woman with abdominal distention was referred to our hospital. CT demonstrated a 17 × 11.5‐cm simple cyst replacing the right lobe of the liver, so laparoscopic fenestration was performed. Although the biliary duct could not be detected because of compression by the huge cyst, fluorescent cholangiography with indocyanine green through endoscopic naso‐biliary drainage tube clearly delineated the intrahepatic bile duct in the remaining cystic wall. The patient had no complications at 3 months after surgery. Fluorescent cholangiography using indocyanine green is a safe and effective procedure to avoid bile duct injury during laparoscopic fenestration, especially in patients with a huge liver cyst.

Urgent living donor liver transplantation for biliary atresia complicated by a strangulated internal hernia at Roux-en Y limb: a case report.

BACKGROUND When BA patients with end-stage liver dysfunction have bowel obstruction, especially strangulated internal hernia, selecting optimal surgical therapeutic options is crucial. CASE REPORT An 11-month-old female with end-stage biliary atresia (BA) was admitted for a strangulated internal hernia at the Roux-en Y limb and frequent episodes of gastrointestinal bleeding requiring blood transfusion. She was scheduled within a month to receive a portion of the liver from her blood-type identical mother. Despite intensive care, her clinical condition obviously needed a prompt surgical intervention. The operative findings at laparotomy revealed exudative moderate ascites and a dilated and ischemic afferent loop that was strangulated by a band extending from the mesentery to the transverse mesocolon. The attachment of the band was released, and gangrenous changes were recognized in the incarcerated bowel, although there were no obvious findings of intestinal perforation. After the gangrenous afferent loop was resected, the remnant afferent loop was too short to anastomose again. Following these procedures, as the patients vital signs remained stable, we decided to simultaneously perform living donor liver transplantation (LDLT). She successfully underwent LDLT and her post-transplant course was uneventful. CONCLUSIONS When faced with candidates for LT as an urgent life-saving surgery, determining whether LDLT should be performed simultaneously during perioperative management is necessary to save the life of the patient.

Modified triangular hepatic vein reconstruction for preventing hepatic venous outflow obstruction in pediatric living donor liver transplantation using left lateral segment grafts

HVOO can be a critical complication in pediatric LDLT. The aim of this study was to evaluate a modified triangular technique of hepatic vein reconstruction for preventing HVOO in pediatric LDLT. A total of 298 pediatric LDLTs were performed using a left lateral segment graft by 2 methods for reconstruction of the hepatic vein. In 177 recipients, slit‐shaped anastomosis was indicated with partial clamp of the IVC. A total of 121 recipients subjected to the modified triangular anastomosis with total clamp of the IVC. We compared the incidence of hepatic vein anastomotic complications between these 2 methods. Nine of the 177 cases (5.3%) treated with the conventional technique were diagnosed with outflow obstruction. All 9 cases underwent hepatic vein reconstruction with the slit‐shaped hepatic vein anastomosis. In contrast, there were no cases of outflow obstruction in the 121 cases treated with the modified triangular anastomosis. The modified triangular technique of hepatic vein reconstruction with total clamping of the IVC was useful for preventing HVOO in pediatric LDLT.

Ex vivo reduction of thickness in the left lateral section to tailor the graft size in infantile split deceased donor liver transplantation

Liver transplantation (LT) in infants and small children is still a challenging operation. One obstacle facing this type of operation is the issue of large-for-size grafts because too-large grafts can result in graft compression, splinting of the diaphragm, and abdominal closure with synthetic mesh, which may lead to other complications. Reduction procedures for adult left lateral section (LLS), including hyper-reduced grafts and monosegmental grafts (MSGs), have recently been developed to eliminate size mismatch in living donor liver transplantation (LDLT) for small children. However, although both of those grafts are created by removing excess parts of the LLS to achieve a target graft weight, the graft thickness of hyperreduced grafts cannot be reduced because this strategy employs a simple nonanatomical reduction of the lateral and/or caudal parts of the LLS. Therefore, MSGs of segment 2 are considered more suitable grafts for small children. Recently, MSGs of segment 2 with the preservation of the main Glisson’s pedicle of segment 3 have been increasingly frequently adopted because of the ready accessibility of radiological interventional treatment in the event of biliary and vascular complications. Furthermore, reduction procedures to create MSGs may require precise assessments of anatomical variations of vasculatures and bile ducts inside the LLS, which can lead to safe reduction procedures and eventually reduce the likelihood of surgical complications. However, when procuring a deceased donor liver, oftentimes there is insufficient information available to evaluate the anatomy for creating MSGs. We herein report the ex vivo reduction of an adult deceased LLS to create a MSG in a case of infantile split LT.