Toshiya Shibata

Insulin independence after living-donor distal pancreatectomy and islet allotransplantation

Rising demand for islet transplantation will lead to severe donor shortage in the near future, especially in countries where cadaveric organ donation is scarce. We undertook a successful transplantation of living-donor islets for unstable diabetes. The recipient was a 27-year-old woman who had had brittle, insulin-dependent diabetes mellitus for 12 years. The donor, who was a healthy 56-year-old woman and mother of the recipient, underwent a distal pancreatectomy. After isolation, 408 114 islet equivalents were transplanted immediately. The transplants functioned immediately and the recipient became insulin-independent 22 days after the operation. The donor had no complications and both women showed healthy glucose tolerance. Transplantation of living-donor islets from the distal pancreas can be sufficient to reverse brittle diabetes.

Biliary reconstruction in right lobe living-donor liver transplantation : Comparison of different techniques in 321 recipients

Objective:To assess the incidence of biliary complications after right lobe living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy or Roux-en-Y choledochojejunostomy reconstruction. Summary Background Data:Biliary tract complications remain one of the most serious morbidities following liver transplantation. No large series has yet been carried out to compare the 2 techniques in LDLT. This study undertook a retrospective assessment of the relation between the method of biliary reconstruction used and the complications reported. Methods:Between February 1998 and June 2004, 321 patients received right lobe LDLT. Biliary reconstruction was achieved with Roux-en-Y choledochojejunostomy in 121 patients, duct-to-duct choledochocholedochostomy in 192 patients, and combined Roux-en-Y and duct-to-duct choledochocholedochostomy in 8 patients. The number of graft bile duct and anastomosis, mode of anastomosis, use of stent tube, and management of biliary complications were analyzed. Results:The overall incidence of biliary complications was 24.0%. Univariate analysis revealed that hepatic artery complications, cytomegalovirus infections, and blood type incompatibility were significant risk factors for biliary complications. The respective incidence of biliary leakage and stricture were 12.4% and 8.3% for Roux-en-Y, and 4.7% and 26.6% for duct-to-duct reconstruction. Duct-to-duct choledochocholedochostomy showed a significantly lower incidence of leakage and a higher incidence of stricture; however, 74.5% of the stricture was managed with endoscopic treatment. Conclusions:The authors found an increase in the biliary stricture rate in the duct-to-duct choledochocholedochostomy group. Because of greater physiologic bilioenteric continuity, less incidence of leakage, and easy endoscopic access, duct-to-duct reconstruction represents a feasible technique in right lobe LDLT.

Successful islet transplantation from nonheartbeating donor pancreata using modified ricordi islet isolation method

Background. Current success of islet transplantation has led to donor shortage and the need for marginal donor utilization to alleviate this shortage. The goal of this study was to improve the efficacy of islet transplantation using nonheartbeating donors (NHBDs). Methods. First, we used porcine pancreata for the implementation of several strategies and applied to human pancreata. These strategies included ductal injection with trypsin inhibitor for protection of pancreatic ducts, ET-Kyoto solution for pancreas preservation, and Iodixanol for islet purification. Results. These strategies significantly improved both porcine and human islet isolation efficacy. Average 399,469±36,411 IE human islets were obtained from NHBDs (n=13). All islet preparations met transplantation criteria and 11 out of 13 cases (85%) were transplanted into six type 1 diabetic patients for the first time in Japan. All islets started to secrete insulin and all patients showed better blood glucose control without hypoglycemic loss of consciousness. The average HbA1c levels of the six recipients significantly improved from 7.5±0.4% at transplant to 5.1±0.2% currently (P<0.0003). The average insulin amounts of the six recipients significantly reduced from 49.2±3.3 units at transplant to 11±4.4 units (P<0.0005) and five out of six patients reduced to less than half dose. The first patient is now insulin free, the first such case in Japan. Conclusion. This demonstrates that our current protocol makes it feasible to use NHBDs for islet transplant into type 1 diabetic patients efficiently.

Cholangitis and Liver Abscess after Percutaneous Ablation Therapy for Liver Tumors: Incidence and Risk Factors

PURPOSE To determine the risk factors of cholangitis and liver abscess occurring after percutaneous ablation therapy for liver tumors. MATERIALS AND METHODS Between October 1995 and September 2002, 358 patients with 455 liver tumors underwent a total of 683 ablation procedures, such as percutaneous ethanol injection (PEI), percutaneous microwave coagulation (PMC), and radiofrequency (RF) ablation therapy. With a retrospective review of medical records, the rates and outcomes of cholangitis and/or liver abscess occurring after ablation therapy were evaluated. The relationship between cholangitis and/or liver abscess and multiple variables (age, disease, Child-Pugh class, size of nodules, multiplicity of nodules, history of transcatheter arterial embolization, presence of bilioenteric anastomosis, and lack of prophylactic antibiotics administration) were statistically analyzed. RESULTS Cholangitis and/or liver abscess occurred in 10 sessions (1.5%) in 10 patients: six sessions after PEI, three sessions after PMC, and one session after RF ablation. Both cholangitis and liver abscess were noted in seven sessions, cholangitis was noted in two, and liver abscess was noted in one. Six patients recovered, but two developed recurrent cholangitis and liver abscess, one developed lung abscess complicated with liver abscess, and one died of septic shock associated with cholangitis. On stepwise regression analysis, bilioenteric anastomosis was the sole significant predictor of cholangitis and/or liver abscess formation (P <.001; odds ratio = 36.4; 95% CI = 9.67-136.9). CONCLUSION Bilioenteric anastomosis strongly correlated with the development of cholangitis and/or liver abscess after percutaneous ablation therapy. Close posttreatment attention should be paid to this subgroup of patients.

Treatment of ruptured hepatocellular carcinoma.

AbstractBackground. The problem of whether surgical or conservative treatment is indicated for ruptured hepatocellular carcinoma (HCC) has not been analyzed from the viewpoint of long-term development of hepatitis viral infection from liver fibrosis to liver cirrhosis. Although transcatheter arterial embolization (TAE) for hemostasis followed by two-stage hepatectomy has been established as the best treatment for ruptured HCC, there still remain difficulties in the treatment of some patients. Methods. Twelve patients with ruptured HCC who were surgically or conservatively treated were retrospectively analyzed in terms of modality of treatment, liver function, extension of HCC, complications, survival rate, and cause of death. Results. Tumor rupture can occur either in the early phase or in the terminal phase during the development from liver fibrosis to liver cirrhosis, while tumor rupture occurs at the advanced stage in terms of HCC extension. TAE for emergent hemostasis or prevention of re-bleeding was performed in ten patients, while TAE was contraindicated in one patient and emergent laparotomy for hemostasis was performed in one patient. In four patients, elective extended surgical resection was performed, because liver function was evaluated as clinical stage 1 according to the General rules for the clinical and pathological study of primary liver cancer of the Liver Cancer Study Group of Japan. In seven patients, conservative or medical treat-ment was selected, because liver function was evaluated as poor. The surgically treated group, who could tolerate extensive operation, survived longer than the conservatively treated group. Conclusions. While TAE remains the best method to employ for hemostasis, it still has limitations. Hence, we should be mindful of other possible modalities for hemostasis and their outcomes. Rupture of HCC at an early phase in the development of liver fibrosis is a good indication for elective surgical treatment and should be distinguished from rupture in the terminal phase of liver cirrhosis, which should be treated conservatively. Although elective surgical treatment can be performed in selected patients, tumor size and location of HCC, in addition to liver function, should be taken into consideration.

Hepatic venous outflow obstruction in pediatric living donor liver transplantation using left‐sided lobe grafts: Kyoto university experience

The goals of this study were to evaluate the incidence of hepatic venous outflow obstruction (HVOO) in pediatric patients after living donor liver transplantation (LDLT) using left‐sided lobe grafts and to assess the therapeutic modalities used for the treatment of this complication at a single center. Four hundred thirteen primary LDLT procedures were performed with left‐sided lobe grafts between 1996 and 2006. All transplants identified with HVOO from a cohort of 380 grafts with survival greater than 90 days were evaluated with respect to the patient demographics, therapeutic intervention, recurrence, and outcome. Seventeen cases (4.5%) were identified with HVOO. Eight patients experienced recurrence after the initial balloon venoplasty. Two patients finally required stent placement after they experienced recurrence shortly after the initial balloon venoplasty. A univariate analysis revealed that a smaller recipient‐to‐donor body weight ratio and the use of reduced grafts were statistically significant risk factors. The cases with grafts with multiple hepatic veins had a higher incidence of HVOO. In conclusion, the necessity of repeated balloon venoplasty and stent placement was related to poor graft survival. Therefore, the prevention of HVOO should be a high priority in LDLT. When grafts with multiple hepatic veins and/or significant donor‐recipient size mismatching are encountered, the use of a patch graft is recommended. Stent placement should be carefully considered because of the absence of data on the long‐term patency of stents and stent‐related complications. New stenting devices, such as drug‐eluting and biodegradable stents, may be promising for the management of HVOO. Liver Transpl 16:1207–1214, 2010.

Non-contrast-enhanced MR portography with time-spatial labeling inversion pulses: comparison of imaging with three-dimensional half-fourier fast spin-echo and true steady-state free-precession sequences.

To compare and evaluate images acquired with two different MR angiography (MRA) sequences, three‐dimensional (3D) half‐Fourier fast spin‐echo (FSE) and 3D true steady‐state free‐precession (SSFP) combined with two time‐spatial labeling inversion pulses (T‐SLIPs), for selective and non‐contrast‐enhanced (non‐CE) visualization of the portal vein.

Percutaneous Radiofrequency Ablation Therapy after Intrathoracic Saline Solution Infusion for Liver Tumor in the Hepatic Dome

Two liver tumors undetected by ultrasonography (US) because they were located in the hepatic dome were treated with radiofrequency (RF) ablation therapy after intrathoracic saline solution infusion. After administration of local anesthesia, artificial pneumothorax was produced by needle thoracentesis and a drainage catheter was inserted into the right thoracic cavity. After saline solution (450-500 mL) was injected into the thoracic cavity via the catheter, US-guided RF ablation was performed. No severe complications occurred and complete therapeutic effects were obtained. Percutaneous RF ablation therapy with intrathoracic saline solution injection seems to be a feasible alternative to other ablation therapies.

Transcatheter Microcoil Embolotherapy for Ruptured Pseudoaneurysm Following Pancreatic and Biliary Surgery

Purpose: To evaluate the outcome of transcatheter microcoil embolotherapy for bleeding pseudoaneurysms complicating major pancreatic and biliary surgery. Materials and Methods: Over an 8-year period, 8 patients were encountered who developed massive bleeding from pseudoaneurysms 15–64 days (mean 31 days) following major pancreatic and biliary surgery. Urgent transcatheter microcoil embolotherapy was performed in all 8 patients. Results: Transcatheter embolotherapy was successful in 7 of 8 patients (88%) but failed in one due to development of disseminated intravascular coagulation. One patient developed recurrent bleeding 36 days after the first embolotherapy from a newly developed pseudoaneurysm, which was again treated successfully with embolization. Two patients subsequently underwent additional surgery for residual pathology. Three of the 7 patients with successful embolotherapy were alive at 10–96 months, 4 patients died of associated malignancies 4–20 months after embolotherapy. Conclusion: Transcatheter microcoil embolotherapy is effective for bleeding pseudoaneurysms complicating pancreatic and biliary surgery, and should be considered the first treatment of choice.

Hepatic Lesions: Improved Image Quality and Detection with the Periodically Rotated Overlapping Parallel Lines with Enhanced Reconstruction Technique—Evaluation of SPIO-enhanced T2-weighted MR Images

PURPOSE To evaluate the effectiveness of the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) technique for superparamagnetic iron oxide (SPIO)-enhanced T2-weighted magnetic resonance (MR) imaging with respiratory compensation with the prospective acquisition correction (PACE) technique in the detection of hepatic lesions. MATERIALS AND METHODS The institutional human research committee approved this prospective study, and all patients provided written informed consent. Eighty-one patients (mean age, 58 years) underwent hepatic 1.5-T MR imaging. Fat-saturated T2-weighted turbo spin-echo images were acquired with the PACE technique and with and without the PROPELLER method after administration of SPIO. Images were qualitatively evaluated for image artifacts, depiction of liver edge and intrahepatic vessels, overall image quality, and presence of lesions. Three radiologists independently assessed these characteristics with a five-point confidence scale. Diagnostic performance was assessed with receiver operating characteristic (ROC) curve analysis. Quantitative analysis was conducted by measuring the liver signal-to-noise ratio (SNR) and the lesion-to-liver contrast-to-noise ratio (CNR). The Wilcoxon signed rank test and two-tailed Student t test were used, and P < .05 indicated a significant difference. RESULTS MR imaging with the PROPELLER and PACE techniques resulted in significantly improved image quality, higher sensitivity, and greater area under the ROC curve for hepatic lesion detection than did MR imaging with the PACE technique alone (P < .001). The mean liver SNR and the lesion-to-liver CNR were higher with the PROPELLER technique than without it (P < .001). CONCLUSION T2-weighted MR imaging with the PROPELLER and PACE technique and SPIO enhancement is a promising method with which to improve the detection of hepatic lesions. (c) RSNA, 2009.