Yasunari Ohno

Long-term results of living-related donor liver graft transplantation: a single-center analysis of 110 transplants.

BACKGROUND Difficulties of cadaveric donation and serious donor shortage have led to the development and popularization of living-related donor liver graft transplantation (LRLT). Because the history of this procedure is rather short, important aspects specific to this procedure have not been sufficiently documented. The objective of this study was to analyze a single centers 10-year experience with 110 LRLT in pediatric and adult patients with end-stage liver diseases. METHODS The medical records of 110 consecutive patients who underwent LRLT were reviewed. The recipients were comprised of 72 children and 38 adults. The graft volume corresponded to 26-192% of the recipients standard liver volume. The relationship between pretransplant covariates and patient and graft survival was analyzed. Actuarial patient/graft survival rates were determined at 1, 3, and 5 years. The type and incidence of posttransplant complications were analyzed, as was long-term graft function. RESULTS The 1-, 3-, and 5-year actuarial patient and graft survival rates were 88%, 85%, and 85%, respectively. Log-rank test demonstrated that ABO-compatibility predicted patient survival rate, whereas patient age, underlying disease, patients clinical status, donor-recipient relation, donor age, and graft volume/standard liver volume ratio did not. Long-term liver function remains excellent. All the donors have returned to normal daily lives with an uneventful course. CONCLUSIONS LRLT is an efficacious procedure that provides excellent short-term and long-term survival. The indication criteria for both recipient and donor were legitimate in this series, except for transplant across ABO-incompatibility. Cautious expansion of this procedure may be justified under the situation of serious shortage of cadaveric donor.

Prognosis of Adult Patients Transplanted with Liver Grafts < 35% of Their Standard Liver Volume

We have previously reported that a graft volume (GV) > 30% of the recipients standard liver volume (SLV) can meet the recipients metabolic demands. Here we report our experience with adult‐to‐adult living donor liver transplantation using left side grafts < 35% of the recipients SLV. Of 143 adult living donor liver transplants, 13 auxiliary partial orthotopic liver transplants, 8 right side grafts, and 2 retransplantation cases were excluded. The resulting 120 cases were divided into 2 groups: group S consisted of 33 patients who received liver grafts < 35% of their SLV, and group L consisted of 87 patients who received liver grafts ≥ 35% of their SLV. Patient characteristics, postoperative liver function, duration of hospital stay, and recipient survival rates were compared between the 2 groups. There were no significant differences between groups in recipient or donor background characteristics. The mean GV/SLV ratio of group S was 31.8%, whereas that of group L was 42.5%. There were no significant differences in the postoperative serum total bilirubin levels, prothrombin time international normalized ratio, daily ascites volume, or duration of postoperative hospital stay between the groups. The 1‐ and 5‐year survival rates in group S were 80.7% and 64.2%, respectively, whereas those of group L were 90.8% and 84.9%, respectively, with no significant difference between groups. In conclusion, graft size was not considered to be the only cause of so‐called small‐for‐size graft syndrome, and left side grafting appears to be the procedure of choice for adult‐to‐adult living donor liver transplantation because of the lower risk to donors in comparison with right lobe grafting. Liver Transpl 15:1622–1630, 2009.

Nonsurgical policy for treatment of bilioenteric anastomotic stricture after living donor liver transplantation

Biliary complications remain a significant cause of morbidity following living donor liver transplantation. The purpose of this retrospective study was to assess the outcome of nonsurgical management for hepatojejunostomy stricture in our institution. We reviewed 22 patients with hepatojejunostomy stricture among the 231 patients who underwent living donor liver transplantation between June 1990 and December 2005. Hepatojejunostomy stricture was confirmed by percutaneous transhepatic or endoscopic retrograde cholangiography. Anastomotic strictures were treated by balloon dilatation. Percutaneous transhepatic cholangiography was performed on 15 of the 22 patients. Two of 15 patients, with complete obstruction of the anastomosis, were treated successfully by Yamanouchi magnet compression anastomosis. Although another two patients died of infectious disease that was unlikely to have been related to biliary complications, anastomotic patency was maintained in the other 13 patients. Endoscopic retrograde cholangiography was performed on seven of the 22 patients. None of the 22 patients required re‐operation or died of biliary complications. The 5‐year graft survival rate of 85.6% in the 22 patients with stricture was equivalent to that of the patients without stricture (82.9%, P = 0.98). Advances in intervention techniques have enabled wider application of nonsurgical approaches for this complication, and fair results have been obtained.

Temporary Auxiliary Partial Orthotopic Liver Transplantation Using a Small Graft for Familial Amyloid Polyneuropathy

Donor shortage is a major issue in liver transplantation. We have successfully performed temporary auxiliary partial orthotopic liver transplantation (APOLT) using a small volume graft procured from a living donor for recipients with familial amyloid polyneuropathy (FAP). The aim of this study was to evaluate this procedure by comparing it with standard living donor liver transplantation (LDLT). We compared 13 recipients undergoing this procedure with 23 recipients undergoing a standard LDLT for the treatment of FAP. The estimated donor graft volume and the graft volume/recipients standard liver volume ratio were significantly smaller in the temporary APOLT group than in the standard LDLT group. Postoperative complications were comparable, although the hospital stay was longer in the temporary APOLT group. All the patients safely underwent a remnant native liver resection about 2 months after their first operation in the temporary APOLT group. No symptoms related to FAP developed before the remnant liver resection, and no significant differences in graft and patient survival were observed between the two groups. We successfully performed temporary APOLT using a small volume liver graft without postoperative liver failure for FAP. Temporary APOLT for FAP might be a useful alternative procedure for expanding the donor pool for LDLT.

Administration of Dalteparin Based on the Activated Clotting Time for Prophylaxis of Hepatic Vessel Thrombosis in Living Donor Liver Transplantation

Beginning in 2004, dalteparin doses based on activated clotting time (ACT) were administered for hepatic vessel thrombosis prophylaxis in living donor liver transplantation (LDLT). We verified the feasibility of this new therapy by comparing it with the previous one. From 1993 through 2008, 42 metabolic liver patients who underwent LDLT were divided into two groups. Group A (1993-2003, n = 32) was administered a fixed dalteparin dose and a large amount of fresh frozen plasma (FFP); Group B (2004-2008, n = 10) was administered an appropriate dosage of dalteparin to maintain the ACT levels from 140 to 150 seconds and a small amount of FFP. Group B was administered a lesser amount of FFP and more dalteparin. This resulted in longer activated partial thromboplastin time, lower fibrinogen degradation products D-dimer, and lower aspartate aminotransferase levels compared to group A; all differences were significant. Group B showed neither thrombotic nor hemorrhagic complications. Anticoagulation therapy comprising adjustment of the dalteparin dose based on ACT reduces thrombotic complications without increasing hemorrhagic complications. ACT measurement is a simple, reliable method for bedside monitoring of dalteparin anticoagulant effects for LDLT.

Arterial reconstruction in a case of subintimal dissection of celiac arterial tributaries in living donor liver transplantation: a case report.

BACKGROUND Hepatic arterial reconstruction is one of the critical issues in living donor liver transplantation (LDLT). Herein we have reported an LDLT case whose celiac arterial trunk tributaries were insufficient as host arteries because of extensive subintimal dissection proceeding to all tributaries of the celiac arterial trunk. PATIENTS AND METHODS A 45-year-old woman with fulminant hepatic failure underwent LDLT. After reperfusion of the hepatic and portal veins, subintimal dissection of the recipient right and left hepatic arteries was found to extend to all tributaries of the celiac arterial trunk, preventing an anastomosis using the more proximal part of these arteries. Therefore, a jejunal arterial arcade of Roux-en-Y limb mobilized for biliary reconstruction was anastomosed to the donor left hepatic artery in end-to-end fashion. RESULTS Arterial blood flow to the grafted liver was established successfully, and the patients postoperative recovery was excellent. Postoperative computed tomography demonstrated sufficient hepatic arterial blood flow. The patient is doing well 4 years after transplantation. CONCLUSION The method of hepatic graft arterialization described herein is an important option for LDLT recipients when tributaries of the celiac arterial trunk are insufficient as host arteries.

Optimal Initial Dose of Orally Administered Once-daily Extended-release Tacrolimus Following Intravenous Tacrolimus Therapy After Liver Transplantation

INTRODUCTION Once-daily extended-release tacrolimus (Tac-OD) is expected to reduce non-adherence in recipients after liver transplantation (LT). The aim of this study was to determine the optimal initial dose of orally administered Tac-OD after intravenous tacrolimus (Tac-IV) therapy after LT. PATIENTS AND METHODS This prospective study included 10 adult recipients who had undergone LT at our institute. The recipients were prescribed tacrolimus by continuous intravenous administration with a steroid as initial immunosuppression therapy. Tacrolimus was converted from intravenous administration to once-daily oral intake when gastrointestinal function returned. We evaluated tacrolimus concentrations in blood 9 times a day and area under the blood concentration-time curve (AUC) during conversion. The optimal initial dose of Tac-OD was determined based on simple regression analysis between the oral dose of Tac-OD and the total dose of Tac-IV during a 24-hour period. RESULTS The AUC before and after conversion showed no differences. We found that the optimal initial dose of Tac-OD was 8 times the dose of Tac-IV. There was a relationship between the AUC and the trough level. No recipients experienced acute rejection or adverse effects such as renal failure, neurotoxicity, or cardiac failure during conversion. CONCLUSIONS We successfully converted continuous Tac-IV to oral intake of Tac-OD by adjusting the dose using trough levels without acute rejection or adverse effects. The AUC of Tac-OD correlated with the trough level. The optimal initial dose ratio of Tac-OD after Tac-IV was 8:1.

A New procedure for temporary auxiliary partial liver transplantation using living donor graft for patients with familial amyloid polyneuropathy

To introduce duct‐to‐duct biliary anastomosis to conventional temporary auxiliary partial orthotopic liver transplantation (APOLT) using living donor graft for patients with familial amyloid polyneuropathy, we modified the conventional APOLT procedure in a manner characterized by the use of the recipients common hepatic duct for biliary reconstruction and the preservation of the right posterior section alone for the certain placement of a tube into the corresponding biliary tree for external biliary drainage (modified APOLT). This procedure was performed in 3 patients without biliary complications. No complications associated with the external drainage tube occurred. Here we report the techniques and results for this new procedure. Liver Transpl, 2012.

Clinicopathological features of hepatitis C virus disease after living donor liver transplantation: relationship with in situ hybridisation data

Aims: Recurrent hepatitis is a significant complication after liver transplantation for hepatitis C virus (HCV) disease. To evaluate responsiveness to treatment of HCV disease after liver transplantation, in situ hybridisation (ISH) was employed. Methods: Sense and anti-sense probes for HCV were synthesised, and ISH studies were performed on 19 liver biopsy specimens from 19 recipients who had undergone living donor liver transplantation for HCV disease. ISH positive cells and total hepatocytes were counted, and the percentage of positive cells was calculated. Other clinical findings were compared retrospectively with the ISH results. Results: The subjects were divided into three groups: recurrent HCV hepatitis (RHC, n = 11), acute cellular rejection (ACR, n = 5), and recurrent HCV hepatitis with ACR (MIX, n = 3). The percentage of ISH positive cells was almost the same degree (10–20%) in the three groups. The RHC group was subdivided into two sets of patients in whom serum HCV titres decreased (group D, n = 7) or did not decrease (group ND, n = 3) after 1 month of IFN therapy. The percentage of ISH positive cells in group D was significantly lower than that in group ND (p < 0.05) Conclusions: ISH for the recipients with HCV may be useful for predicting the response to interferon therapy.

Glucose Management during Insulinoma Resection Using Real-Time Subcutaneous Continuous Glucose Monitoring

Insulinoma is a rare neuroendocrine tumor that causes hypoglycemia due to unregulated insulin secretion. Blood glucose management during insulinoma resection is therefore challenging. We present a case in which real-time subcutaneous continuous glucose monitoring (SCGM) in combination with intermittent blood glucose measurement was used for glycemic control during surgery for insulinoma resection. The SCGM system showed the trends and peak of interstitial glucose in response to glucose loading and the change of interstitial glucose before and after insulinoma resection. These data were helpful for adjusting the glucose infusion; therefore, we think that an SCGM system as a supportive device for glucose monitoring may be useful for glucose management during surgery.