Y Kita

A case of successful enteroscopic balloon dilation for late anastomotic stricture of choledochojejunostomy after living donor liver transplantation.

Biliary complications remain a major concern after living donor liver transplantation. We describe a pediatric case who underwent a successful endoscopic balloon dilatation of biliary‐enteric stricture following living donor liver transplantation using a newly developed method of enteroscopy. The 7‐year‐old boy with late biliary stricture of choledochojejunostomy was admitted 6 years after transplantation. Since percutaneous transhepatic cholangiography was technically difficult in this case, endoscopic retrograde cholangiography was performed using a double‐balloon enteroscope under general anesthesia. The enteroscope was advanced retrograde through the duodenum, jejunum, and the leg of Roux‐Y by the double‐balloon method, and anastomotic stricture of choledochojejunostomy was clearly confirmed by endoscopic retrograde cholangiography and endoscopic direct vision. Balloon dilatation was performed and the anastomosis was expanded. Restenosis was not noted as of 2 years after the treatment. In conclusion, endoscopic balloon dilation of biliary‐enteric anastomotic stricture using a new enteroscopic method can be regarded as an alternative choice to percutaneous transhepatic management and surgical re‐anatomists. (Liver Transpl 2005;11:1608–1610.)

Gastrointestinal bleeding after living-related liver transplantation

We examined the prevalence of gastrointestinal bleeding in patients undergoing living-related liver transplantation (LRLT). Seventy-seven patients (37 male and 40 female) underwent LRLT at the University of Tokyo Hospital from January 1996 through December 1999. Forty-nine patients were children or adolescents and 28 patients were adults. The mean follow-up period was 21.3 ± 12.8 months. Nine of the 77 recipients had gastrointestinal bleeding after transplantation. The incidence of posttransplant bleeding was significantly higher in adult recipients than in pediatric recipients (25% vs 4%, P < 0.05). The ratio of graft volume to standard liver volume was significantly lower in adult recipients than in pediatric recipients (41 ± 6% vs 86 ± 26%, P < 0.05). Portal vein thrombosis (PVT) developed after LRLT in 8 patients. Variceal bleeding subsequently occurred in all 4 adult patients with PVT but in only 1 of 4 pediatric patients. Small-for-size grafts may cause transient portal hypertension, which increases the risk of gastrointestinal bleeding.

Portal venoplasty for recipients in living-related liver transplantation.

BACKGROUNDnIn living-related liver transplantation (LRLT) in small children, standard end-to-end portal vein (PV) anastomosis is usually difficult because of a inadequate total PV length, or because of a size mismatch between the graft and the recipient PV. In this report, we present our new portal venoplasty technique for the recipient PV.nnnMETHODSnAfter dissection of the recipient PV, the wall between the right and left branches of the PV is severed longitudinally as in the branch patch technique. The anterior and posterior edges of both branches are joined using running sutures, to form a longer and wider PV for anastomosis.nnnRESULTSnThis new portal venoplasty technique was used in 7 of 28 child cases, and gave good results without thrombosis or other complications.nnnCONCLUSIONSnOur new portal venoplasty technique is useful in LRLT in small children when the recipient or graft PV is not long enough.

Arterial waveforms on doppler ultrasonography predicting or supporting hepatic arterial thrombosis in liver transplantation

HEPATIC arterial thrombosis (HAT) is a major cause of patient morbidity and graft loss in liver transplantation. HAT should be diagnosed before the development of liver parenchymal or bile duct damage. Early diagnosis and treatment are essential to salvage grafts. Doppler ultrasound (US) is a useful tool to diagnose HAT. HAT is diagnosed when arterial flow signals are not detected in the graft. However, waveforms on Doppler US predicting or suggesting HAT are not fully understood. In this study, we investigated whether the waveforms on Doppler US can predict or suggest HAT.

Psychiatric problems in living-related transplantation (I): incidence rate of psychiatric disorders in living-related transplantation.

SEVERAL psychiatric follow-up studies are available for recipients and donors after transplantation. To the best of our knowledge, however, there have, to date, been no studies of psychiatric findings among recipients and donors who underwent living-related liver transplantation (LRLT). On the basis of a longitudinal follow-up study, the present study compared the perioperative incidence of psychiatric disorders for two groups of recipients and donors undergoing LRLT and living-related liver transplantation (LRKT), respectively.

Immunosuppressive effect of chenodeoxycholic acid on natural killer cell activity in patients with biliary atresia and hepatitis C virus-related liver cirrhosis.

Patients with severe liver diseases, such as liver cirrhosis and biliary atresia, have low natural killer (NK) cell activity. The relations between NK activity and measures of liver function, including serum levels of total bilirubin, total bile acids, bile acid components, aspartate aminotransferase, and alanine aminotransferase, and platelet count were examined in patients with biliary atresia (6 boys and 6 girls; mean age, 4.8 ± 5.7 years) and patients with liver cirrhosis due to hepatitis C virus infection (10 men and 2 women; mean age, 54.3 ± 13.8 years). Univariate analysis showed that platelet count was positively correlated with NK activity in patients with biliary atresia (r = 0.611, P < 0.05). Serum levels of free chenodeoxycholic acid were negatively correlated with NK activity both in patients with biliary atresia (r = −0.647, P < 0.05) and in patients with hepatitis C virus-related liver cirrhosis (r = −0.876, P < 0.01). None of the other free bile acids or conjugated bile acids or other indicators of liver function were correlated with NK activity. Multiple stepwise regression analysis showed that only levels of free chenodeoxycholic acid were independently correlated with NK activity. All patients with biliary atresia underwent liver transplantation from living related donors. NK activity had increased significantly two months after transplantation (from 24.1 ± 20.2% to 49.2 ± 12.5%, P < 0.01). In contrast, levels of free chenodeoxycholic acid in transplant recipients had decreased significantly two months after transplantation (from 1.22 ± 1.16 to 0.26 ± 0.21 μmol/l, P < 0.05). In conclusion, in patients with biliary atresia or liver cirrhosis, NK activity in peripheral blood decreases, mostly because of free chenodeoxycholic acid.

Increase in natural killer cell activity following living‐related liver transplantation

Abstract We monitored the serial changes of natural killer cell (NK) activity in eight recipients of living‐related liver transplantation. The HLA types of all eight patients were haplotypically identical with those of their donors. Tacrolimus and methylprednisolone were used for immunosuppression. The NK activity before transplantation was 24.1 ± 20.2 % which is surprisingly low when compared with the value for normal individuals (67.7 ± 13.2%, P < 0.01) or a liver dysfunction group (49.4 ± 21.9%, P < 0.05). Serial changes in NK activity revealed a minimum of 6.1 ± 3.6% 1 week after transplantation, gradually increasing to 49.2 ± 12.5 % at 2 months after transplantation. These results suggest that the diseased liver might play an important role in the suppression of NK activity.

Successful Treatment of Sepsis with Polymyxin B-Immobilized Fiber Hemoperfusion in a Child After Living Donor Liver Transplantation

To the Editor: A 13-month-old boy underwent living donor liver transplantation to treat end-stage liver disease due to biliary atresia. The donor was the boy’s father. The postoperative course was uneventful except for a persistent pleural effusion. On the 46th postoperative day the patient suddenly exhibited a high fever (104◦F), decreased blood pressure (90/40 mm Hg), tachycardia (184 bpm), and dyspnea. Urine output also decreased rapidly (<0.2 ml/kg/hr for 3 hr). Laboratory studies showed a decreased platelet count (2.6 × 104/μL), an increased white blood cell count (16,100/μL), and increased levels of C-reactive protein (15.8 mg/dL), alkaline phosphatase (521 U/L; normal, 89– 285 U/L), and γ -glutamyl transpeptidase (87 U/L; normal, <70 U/L). The serum concentration of endotoxin measured with an endotoxin-specific assay (Endospecy; Seikagakukogyo, Tokyo) was 63.2 pg/mL, indicating hyperendotoxemia, and Pseudomonas aeruginosa was detected with blood culture. Cultures of the pleural effusion yielded no microorganisms. Pseudomonas aeruginosa endotoxemia and prerenal acute renal failure were diagnosed. Bacterial cholangitis was a possible cause because the bacteria were the same as those in the intraoperative bile juice culture. Antibiotic therapy with gentamicin, cefepime, and aztreonam was started soon after the diagnosis was established. Dopamine was also administered. However, the blood pressure was difficult to maintain and oliguria persisted for 2 days. Two days after the patient was admitted to the intensive care unit, emergency polymyxin B-immobilized fiber (PMX-F) hemoperfusion was performed twice. Because the patient weighed only 8 kg, a pediatric hemoperfusion column (PMX-05R; Asahi Medical Co., Ltd., Tokyo) and circuit (CHF-704N; Asahi Medical) were used. Total priming volume was 77.7 mL. A mixture of a red blood cell suspension and physiological saline was used to prime the hemoperfusion column and circuit. The blood flow rate was 30 mL/min. The patient’s hemodynamic condition was stable during PMX hemoperfusion. The concentration of endotoxin decreased markedly (63.2 to 2.2 pg/mL) after the first PMX-F hemoperfusion and did not increase thereafter. After PMX-F hemoperfusion, the patient’s hyperdynamic status was markedly improved and makers of inflammation were normalized. In this patient, endotoxin shock and prerenal acute renal failure developed concurrently owing to Pseudomonas aeruginosa sepsis. In such a severe case of sepsis, both the focus of infection and the systemic inflammatory response syndrome must be treated. PMX-F hemoperfusion is an effective treatment for both conditions (1). Although PMX is effective for treating septic shock in adults (2, 3), it has rarely been used in children. Children’s smaller bodies and lower circulating blood volumes must be kept in mind when PMX-F hemoperfusion is performed. Blood purification by extracorporeal circulation is often avoided in children because of their low circulating blood volumes, but we believe that PMX-F hemoperfusion is a useful treatment for pediatric septic shock after organ transplantation.

Psychiatric problems in living-related transplantation (III): pretransplant psychological assessment in living-related transplantation.

ECAUSE of rapid advances in surgical techniques and in the management of infection and rejection, the number of organ transplants has been increasing. Adult-toadult living-related liver transplantation (LRLT) has been necessary in Japan because organ donation from cadaveric donors is rare, even though the Diet (legislature) approved the procedure in 1998. In the United States, cadaveric organs have provided a source for liver transplantation, but the number of donations from brain-dead donors is insufficient to meet demand. Although they are infrequently verbalized in Japanese culture, psychological conflicts are evident among donors. In our previous studies, we reported abnormal findings in a projective drawing test administered to the recipients and donors immediately prior to living-related kidney transplantation (LRKT). 1‐3 These abnormalities were associated with clinical expressions of anxiety. There is, as yet, no predictive data (of which we are aware) on the relationship between preoperative projective testing and the incidence of psychiatric symptoms after living-related transplantation. In the present study we performed pretransplant psychological assessment in living-related transplantation.

A simple method to avoid a biliary complication after living-related liver transplantation

LIVING-related partial liver transplantation (LRLT) produced encouraging results, with a more than 80% 5-year patient survival rate despite the complicated and elaborate procedure in comparison with cadaveric whole organ transplantation. However, the incidence of biliary complications after LRLT has been reported to be 4.3% to 35%. Avoiding biliary complications is important because these often lead to other infectious sequelae. Dilatation of bile ducts in the grafts after LRLT has been reported in the literature. One of the causes of this complication is an inadvertent suture or tie in the donor operation or bench surgery. If the patency of the bile ducts to each liver segment is confirmed during the recipient operation, this kind of complication can be avoided. We present a simple and useful technique to examine the patency of the segmental bile duct branches in the liver grafts using a surgical probe and ultrasonography.