Yukui Ma

Living donor liver transplantation for Budd‐Chiari syndrome using cryopreserved vena cava graft in retrohepatic vena cava reconstruction

Objective To report the authors experience with the first case of an adult-to-adult living donor liver transplantation (LDLT) for Budd-Chiari syndrome (BCS) using cryopreserved vena cava graft in postheptic vena cava reconstruction. Methods A 35-year-old male patient with a diagnosis of BCS complicated with inferior vena cava (IVC) obstruction received medical treatment and radiologic intervention for nine months, no relief of the symptoms could be achieved. Finally, the patient underwent LDLT, which required posthepatic vena cava reconstructed using cryopreserved vena cava graft. Results The patient has had an uneventful course since the LDLT. Conclusion We believe that LDLT combined with posthepatic IVC reconstruction using cryopreserved vena cava graft is considered to be a sound modality for IVC obstructed BCS.

A Significant Expansion of CD8+ CD28- T-Suppressor Cells in Adult-to-Adult Living Donor Liver Transplant Recipients

BACKGROUND The appearance of human regulatory CD8(+) CD28(-) T-suppressor (Ts) cells has been associated with a reduced need for maintenance immunosuppression in cadaveric heart- kidney transplant recipients and pediatric liver-intestine transplant recipients. However, few data are available in adult-to-adult living donor liver transplantation (A-A LDLT). MATERIALS AND METHODS To study the population of CD8(+) CD28(-) Ts cells in A-A LDLT, we performed flow cytometry on whole blood specimens obtained from 20 transplant recipients, 18 end-stage liver disease patients, and 20 normal controls. Meanwhile, we measured the trough levels of immunosuppressants and monitored graft function in transplant recipients. We retrospectively reviewed the clinical data of the 20 recipients. RESULTS A significant expansion of CD8(+) CD28(-) Ts cells was observed among recipients of A-A LDLT as compared with a disease control group (P = .000) or healthy individuals (P = .000). All recipients were free of acute cellular rejection episodes. During the follow-up period, no grafts were lost due to acute or chronic rejection. CONCLUSION Expansion of CD8(+) CD28(-) Ts cells in A-A LDLT seemed to be associated with a decreased occurrence of acute or chronic rejection and sustained good graft function. Based on our low dosages of immunosuppressants for recipients of A-A LDLT, we suggest that this strategy may promote expansion of CD8(+) CD28(-) Ts cells, which can conversely maintain the low immunosuppressant dosages.

Preliminary experience for reducing biliary complication in adult-to-adult living donor liver transplantation using right lobe graft

Aim:  To report the author’s preliminary experience with adult‐to‐adult living donor liver transplantation (LDLT) using right lobe liver grafts.

Risk factors associated with early and late HAT after adult liver transplantation

AIM To identify risk factors that might contribute to hepatic artery thrombosis (HAT) after liver transplantation (LT). METHODS The perioperative and follow-up data of a total of 744 liver transplants, performed from February 1999 to July 2010, were retrospectively reviewed. HAT developed in 20 patients (2.7%). HAT was classified as early (occurring in fewer than 30 d post LT) or late (occurring more than 30 d post LT). Early HAT developed in 14 patients (1.9%). Late HAT developed in 6 patients (0.8%). Risk factors associated with HAT were analysed using the χ(2) test for univariate analysis and logistic regression for multivariate analysis. RESULTS Lack of ABO compatibility, recipient/donor weight ratio ≥ 1.15, complex arterial reconstruction, duration time of hepatic artery anastomosis > 80 min, duration time of operation > 10 h, dual grafts, number of units of blood received intraoperatively ≥ 7, number of units of fresh frozen plasma (FFP) received intraoperatively ≥ 6, postoperative blood transfusion and postoperative FFP use were significantly associated with early HAT in the univariate analysis (P < 0.1). After logistic regression, independent risk factors associated with early HAT were recipient/donor weight ratio ≥ 1.15 (OR = 4.499), duration of hepatic artery anastomosis > 80 min (OR = 5.429), number of units of blood received intraoperatively ≥ 7 (OR = 4.059) and postoperative blood transfusion (OR = 6.898). Graft type (whole/living-donor/split), duration of operation > 10 h, retransplantation, rejection reaction, recipients with diabetes preoperatively and recipients with a high level of blood glucose or diabetes postoperatively were significantly associated with late HAT in the univariate analysis (P < 0.1). After logistic regression, the independent risk factors associated with early HAT were duration of operation > 10 h (OR = 6.394), retransplantation (OR = 21.793) and rejection reactions (OR = 16.936). CONCLUSION Early detection of these risk factors, strict surveillance protocols by Doppler ultrasound and prophylactic anticoagulation for recipients at risk might be determined prospectively.

Arterial Complications After Living-Related Liver Transplantation: Single-Center Experience From West China

Vascular complications after liver transplantation remain a major source of morbidity and mortality for recipients. In particular, patients receiving living-related liver transplantation (LRLT) experience a higher rate of vascular complications owing to the complex vascular reconstruction. Between July 2001 and December 2005, LRLTs were performed in our center on 33 patients with end-stage liver diseases. The 23 men and 10 women had a mean age of 32.6 +/- 11.3 years (range = 5 to 58 years). Of the 33 patients, the percentage of vascular complications was 9.09% (3 cases), including hepatic arterial thrombosis (HAT), hepatic arterial stenosis (HAS), or hepatic artery pseudoaneurysm (HAP) in one patient, respectively. No portal vein or hepatic vein complication occurred in our patients. Thrombectomy was performed in the patient with thrombosis. The patient with stenosis was treated with balloon angioplasty and endoluminal stent placement. The pseudoaneurysm was also successfully embolized to restore the blood flow toward the donor liver. Mean follow-up for all patients after LRLT was 18.0 +/- 5.4 months. The overall postoperative 30-day mortality rate was 6.06% (2/33). The 1-year survival rate was 86.36% in 22 patients with benign diseases and 72.73% in 11 patients with malignant diseases. However, no death was associated with vascular complications. Careful preoperative evaluation and intraoperative microsurgical technique for hepatic artery reconstructions are the keys to prevent vascular complications following LRLT. Immediate surgical intervention is required for acute vascular complications, whereas late complications may be treated by balloon angioplasty and endoluminal stent placement. Embolization may be a safe and effective approach in the treatment of a pseudoaneurysm of the hepatic artery.

Successful adult‐to‐adult living donor liver transplantation combined with a cadaveric split left lateral segment

The shortage of cadaveric livers has sparked an interest in adult-to-adult living donor liver transplantation (LDLT). LDLT may increase the liver graft pool and reduce waiting list mortality. Right-lobe donor hepatectomy is frequently required to obtain a graft of adequate size for adult recipients. Nevertheless, small-for-size syndrome is still a clinical syndrome described following liver transplantation and extended hepatectomy. Now, to expand the donor pool to relieve the pressure of the increasing number of liver transplantation candidates, clinicians are continually modifying criteria to accept organs, particularly those in the so-called expanded or marginal donor pool. Thus, the extension of LDLT to the adult recipient is obviously limited by SFSS and the safety of the donor. How can the contradiction of the donor and the recipient be solved, how can SFSS be prevented, and how can the safety of living donor be ensured? Here, we report our experience with adult-toadult LDLT combined split liver from a cadaveric donor. Lee et al. first reported LDLT using cadaveric split liver in 2001. In their report, 1 recipient received 1 left lobe from a living donor and 1 split left lateral segment from a cadaveric donor. However, our procedure isn’t identical to Lee’s, and our patient received 1 right lobe without a middle hepatic vein from a living donor and 1 split left lateral segment from a cadaveric donor. Theoretically, our method will show less postoperative complications than Lee’s method, because a living right lobe and a split lateral segment could be implanted orthotopically in their original position in our case, and rotation of the donor isn’t needed. Remarkably, we have followed up on the recipient for over 9 months after the operation, and we stress the information of computed tomography after the operation in the article. This article may be the first to report on the use of computed tomography for LDLT using cadaveric split liver. We provide more direct evidence for the procedure to be applied in clinical practice. In our case, the recipient was 35-year-old male (height,160 cm; weight, 70 kg; blood type B), and he was diagnosed as hepatitis B–related cirrhosis, and splenic hyperfunction. He experienced abdominal fullness for 1 year and had swelling of the 2 lower limbs. The living donor was the recipient’s mother, a 56year-old woman (height, 147 cm; weight, 52 kg; blood type O) who was generally healthy. The preoperative computed tomography scan calculated the total volume of the donor’s liver to be 1,333.83 cm. The volume of the right lobe of the liver, excluding the middle hepatic vein, was estimated to be 756.96 cm. Endoscopic retrograde cholangiography was performed to identify the precise anatomy of the bile duct. The right lobe of the liver, not including the middle hepatic vein, was harvested. The resected right graft weighed 630 g with an estimated volume of 560 mL. The diameter of the right hepatic vein was 2.5 cm, the right portal vein 1.6 cm, and the right inferior hepatic vein 1.4 cm in right donor liver. The remnant liver was the left lobe with the middle hepatic vein, and the left total volume ratio was estimated to be 43%. Not only was the living donor smaller than the recipient in terms of both height and weight, but also her age was relatively old. The graft-to-recipient body weight ratio was only 0.9%. Furthermore, intraoperative fast-

Diabetes mellitus after living donor liver transplantation: data from Mainland China.

Most reported data on posttransplantation diabetes mellitus (PTDM) are from Western countries with patients who underwent deceased donor liver transplantation. A retrospective study was performed to assess the prevalence and predictive factors of PTDM in the context of living donor liver transplantation (LDLT) in the Chinese population using the definition of PTDM proposed in 2003 by the World Health Organization and the American Diabetes Association. The prevalence of DM after LDLT in our study was 25% (21/84), and the incidence of PTDM was 14.9% (11/74) with 64% of cases diagnosed within 3 months after LDLT; 9.5% were observed to show impaired fasting glucose postoperatively. Multivariate analysis identified body mass index >or= 25 kg/m(2) before LDLT as the only independent risk factor for developing PTDM. Only one patient was operated for hepatitis C virus (HCV) infection. Hepatitis B virus (HBV)-related diseases were common in our study population, accounting for 78.6% of all patients. Both HCV and HBV infection status were not independent risk factors for developing PTDM. In addition, a greater tacrolimus trough blood level in the PTDM group versus no-DM group was observed at 3 months post-LDLT (11.03 ng/mL vs 4.87 ng/mL). The mean tacrolimus dose was not significantly different between the two groups. In conclusion, PTDM was prevalent among Chinese LDLT recipients.

Surgical Procedures for Management of Right Portal Venous Branching in Right Lobe Living Donor Liver Transplantation

OBJECTIVE This study sought to describe the surgical management of right portal venous (PV) branches encountered among 104 cases of right lobe living donor liver transplantation (LDLT). METHODS From January 2002 to September 2007, we performed 104 cases of right-lobe LDLT including 11-donors who had anomalous right portal venous branches (APVB). One recipient had PV sponginess hemangioma. The donor right PV branches were type I in 93 cases, type II (trifurcation) in nine cases, and type III in two cases. Except one narrow bridge of tissue excision, the PV branches were transected on the principal of donor priority: PV branches were excised approximately 2 to 3 mm from the confluence while leaving the donors main portal vein and confluence intact. In type II APVB, donor PV branches were obtained with two separate openings in six cases; with two separate openings joined as a common orifice at the back table in two cases, with one common opening with a narrow bridge of tissue in one case. In type III APVB, the donor right anterior and posterior PV branches were obtained with separate openings. The donor right PV branches with one common opening in 92 cases of type I PV branches and a joined common orifice in three cases of type II APVB were anastomosed to the recipients main portal vein or to right branching. As the unavailable recipient PV for sponginess hemangioma, one case of type I right PV branches was end-to-end anastomosed to one of the variceal lateral veins of about 1 cm diameter in a pediatric patient. The PV were reconstructed as double anastomoses in six type II APVB and in one type III APVB obtained with two separate PV openings. In the another type III APVB reconstruction, we successfully utilized a novel U-shaped vein graft interposition. RESULTS The type II APVB donor receiving a narrow bridge of portal vein tissue excision developed portal vein thrombosis on the third postoperative day and underwent reexploration for thrombectomy. There were no vascular complications, such as portal vein thrombosis or stricture among other donors or all recipients. The velocity of blood flow in the U-graft was normal. The anastomosis between the type I donor right portal vein and recipient variceal lateral vein was unobstructed. CONCLUSION Right PV branches should be excised on the principal of donor priority while leaving the donors main portal vein and confluence intact. Single anastomoses was the fundamental procedure of right branch reconstruction. Double anastomoses could be used as the main management for type II and type III APVB reconstruction. U-graft interposition may be a potential procedure for type III APVB reconstruction. Single anastomoses between the donor right portal vein and the recipient variceal lateral vein may be performed when recipient portal vein is unavailable. These innovations for excision and reconstruction of right PV branches were feasible, safe, and had good outcomes.

Preliminary Experience With Indications for Liver Transplantation for Hepatolithiasis

OBJECTIVE The aim of this study was to explore the indications for liver transplantation among patients with hepatolithiasis. PATIENTS AND METHODS Data from 1,431 consecutive patients who underwent surgical treatment from January 2000 to December 2006 were retrospectively collected for analysis. Surgical procedures included T-tube insertion combined with intraoperative cholangioscopic removal of intrahepatic stones, hepatectomy, cholangiojejunostomy, and liver transplantation. RESULTS Nine hundred sixty-one patients who had a stone located in the left or right intrahepatic duct underwent hepatectomy or T-tube insertion combined with intraoperative cholangioscopic removal of intrahepatic stones. The rate of residual stones was 7.5%. Four hundred seventy patients who had a stone located in the bilateral intrahepatic ducts underwent surgical procedures other than liver transplantation; the rate of residual stones was 21.7%. Only 15 patients with hepatolithiasis underwent liver transplantation; they all survived. According to the degree of biliary cirrhosis, recipients were divided into 2 groups: a group with biliary decompensated cirrhosis (n = 7), or group with compensated cirrhosis or no cirrhosis (n = 8). There were significant differences in operative times, transfusion volumes, and blood losses between the 2 groups (P < .05). In the first group, 6 of 7 patients experienced surgical complications, and in the second, 8 recipients recovered smoothly with no complications. Health status, disability, and psychological wellness of all recipients (n = 15) were significantly improved at 1 year after transplantation compared with pretransplantation (P < .05). CONCLUSIONS Liver transplantation is a possible method to address hepatolithiasis and secondary decompensated biliary cirrhosis or difficult to remove, diffusely distributed intrahepatic duct stones unavailable by hepatectomy, cholangiojejunostomy, and choledochoscopy.

Prognostic predictors of patients with carcinoma of the gastric cardia.

BACKGROUND/AIMS This study gives insight into survival predictors and clinicopathological features of carcinoma of the gastric cardia. METHODOLOGY The study included 233 patients who underwent operation for carcinoma of the gastric cardia. Clinicopathological prognostic variables were evaluated as predictors of long-term survival by univariate and multivariate analysis. Cox regression was used for multivariate analysis and survival curves were drawn by the Kaplan- Meier method. RESULTS Carcinoma of the gastric cardia was characterized by positive lymph node metastasis (77.3%), serosal invasion (83.3%) and more stage III or IV tumors (72.5%). Overall 5-year survival rate was 21.9% and median survival period was 24 months. The 5-year survival rate was influenced by tumor size, depth on invasion, lymph node metastasis, extent of lymph node dissection, disease stage, operation methods and resection margin. CONCLUSIONS The absent of serosal invasion and lymph node metastasis, curative resection should be considered to be the favourable predictors of long-term survival of patients with carcinoma of the gastric cardia.