Hepatic artery reconstruction with the jejunal artery of the Roux-en-Y limb in pediatric living donor liver re-transplantation.

When re-anastomosis and re-transplantation becomes necessary after LDLT, arterial reconstruction can be extremely difficult because of severe inflammation and lack of an adequate artery for reconstruction. Frequently, the recipient's HA is not in good condition, necessitating an alternative to the HA. In such cases, the recipient's splenic artery, right gastroepiploic artery or another vessel can be safely used for arterial reconstruction. There have, however, been few reports on using the jejunal artery. Herein, we report our experience with arterial reconstruction using the jejunal artery of the Roux-en-Y limb as an alternative to the HA. A three-yr-old girl who had developed graft failure due to early HA thrombosis after LDLT required re-transplantation. At re-transplantation, an adequate artery for reconstruction was lacking. We reconstructed the artery by using the jejunal artery of the Roux-en-Y limb, as we judged it to be the most appropriate alternative. After surgery, stent was deployed because hepatic blood flow had reduced due to kinking of the anastomosed site, and a favorable outcome was obtained. In conclusion, when an alternative to the HA is required, using the jejunal artery is a feasible alternative.

Interventional radiology for hepatic artery complications soon after living donor liver transplantation in a neonate.

Early hepatic artery complications after liver transplantation in children, having undergone LDLT, can directly affect graft and recipient outcomes, making early diagnosis and treatment essential. In the past, laparotomy (thrombectomy or reanastomosis) was generally employed to treat early hepatic artery complications. Recently, favorable outcomes of IR have been reported. In children, however, the number of such reports is small. To the best of our knowledge, there is no published report on IR applied to neonates with early hepatic artery complications. We recently succeeded in safely using IR for a neonate with early hepatic artery complications after LDLT and obtained a favorable outcome. This case is presented herein.

Pediatric liver retransplantation from living donors can be considered as a therapeutic option for patients with irreversible living donor graft failure.

Liver retransplantation (re-LT) is required in patients with irreversible graft failure, but it is a significant issue that remains medically, ethically, and economically controversial, especially in living donor liver transplantation (LDLT). The aim of this study was to evaluate the outcome, morbidity, mortality, safety and prognostic factors to improve the outcome of pediatric living donor liver retransplantation (re-LDLT). Six of 172 children that underwent LDLT between January 2001 and March 2010 received a re-LDLT and one received a second re-LDLT. The overall re-LDLT rate was 3.5%. All candidates had re-LDLT after the initial LDLT. The overall actuarial survival of these patients was 83.3% and 83.3% at one and five yr, respectively. These rates are significantly worse than the rates of pediatric first LDLT. Vascular complications occurred in four patients and were successfully treated by interventional radiologic therapy. There were no post-operative biliary complications. One case expired because of hemophagocytic syndrome after re-LDLT. Although pediatric re-LDLT is medically, ethically, and economically controversial, it is a feasible option and should be offered to children with irreversible graft failure. Further investigations, including multicenter studies, are therefore essential to identify any prognostic factors that may improve the present poor outcome after re-LDLT.

Living donor liver transplantation for ornithine transcarbamylase deficiency.

Ornithine transcarbamylase deficiency, the most common urea cycle disorder, causes hyperammonemic encephalopathy and has a poor prognosis. Recently, LT was introduced as a radical OTCD treatment, yielding favorable outcomes. We retrospectively analyzed LT results for OTCD at our facility. Twelve children with OTCD (six boys and six girls) accounted for 7.1% of the 170 children who underwent LDLT at our department between May 2001 and April 2010. Ages at LT ranged from nine months to 11 yr seven months. Post-operative follow-up period was 3-97 months. The post-operative survival rate was 91.7%. One patient died. Two patients who had neurological impairment preoperatively showed no alleviation after LT. All patients other than those who died or failed to show recovery from impairment achieved satisfactory quality-of-life improvement after LT. The outcomes of LDLT as a radical OTCD treatment have been satisfactory. However, neurological impairment associated with hyperammonemia is unlikely to subside even after LT. It is desirable henceforth that more objective and concrete guidelines for OTCD management be established to facilitate LDLT with optimal timing while avoiding the risk of hyperammonemic episodes.

Living donor liver transplantation for neonates using segment 2 monosubsegment graft.

The prognosis of liver transplantation for neonates with fulminant hepatic failure (FHF) continues to be extremely poor, especially in patients whose body weight is less than 3 kg. To address this problem, we have developed a safe living donor liver transplantation (LDLT) modality for neonates. We performed LDLTs with segment 2 monosubsegment (S2) grafts for three neonatal FHF. The recipient age and body weight at LDLT were 13-27 days, 2.59-2.84 kg, respectively. S2 or reduced S2 grafts (93-98 g) obtained from their fathers were implanted using temporary portacaval shunt. The recipient portal vein was reconstructed at a more distal site, such as the umbilical portion, to have the graft liver move freely during hepatic artery (HA) reconstruction. The recipient operation time and bleeding were 11 h 58 min-15 h 27 min and 200-395 mL, respectively. The graft-to-recipient weight ratio was 3.3-3.8% and primary abdominal wall closure was possible in all cases. Although hepatic artery thrombosis occurred in one case, all cases survived with normal growth. Emergency LDLT with S2 grafts weighing less than 100 g can save neonates with FHF whose body weight is less than 3 kg. This LDLT modality using S2 grafts could become a new option for neonates and very small infants requiring LT.

Complementary Indicators for Diagnosis of Hepatic Vein Stenosis After Pediatric Living-donor Liver Transplantation.

INTRODUCTION: Although hepatic vein stenosis after liver transplantation is a rare complication, the complication rate of 1% to 6% is higher in pediatric living-donor liver transplantation than that in other liver transplantation cases. Diagnosis is very important because this complication can cause hepatic congestion that develops to liver cirrhosis, graft loss, and patient loss. However, this is unlikely in cases where there are no ascites or hypoalbuminemia. OBJECTIVES: Eleven of 167 patients who had undergone pediatric living-donor liver transplantation were identified in the outpatient clinic at Jichi Medical University as having suffered from hepatic vein stenosis, and were enrolled in the study. METHODS: We conducted a retrospective study in which we reviewed historical patient records to investigate the parameters for diagnosis and examine treatment methods and outcomes. RESULTS: The 11 patients were treated with 16 episodes of balloon dilatation. Three among these received retransplantation and another 2 cases required the placement of a metallic stent at the stenosis. Histological examination revealed severe fibrosis in four of nine patients who had a liver biopsy, with mild fibrosis revealed in the other five grafts. Furthermore, hepatomegaly and splenomegaly diagnosed by computed tomography, elevated levels of hyarulonic acid, and/or a decrease in calcineurin inhibitor clearance were found to be pathognomonic at diagnosis, and tended to improve after treatment. CONCLUSIONS: Diagnosis of hepatic vein stenosis after liver transplantation can be difficult, so careful observation is crucial to avoid the risk of acute liver dysfunction. Comprehensive assessment using volumetry of the liver and spleen and monitoring of hyarulonic acid levels and/or calcineurin inhibitor clearance, in addition to some form of imaging examination, is important for diagnosis and evaluation of the effectiveness of therapy.

Chronopharmacology for deoxyspergualin: toxicity and efficacy in the rat.

BACKGROUND: Deoxyspergualin (DSG), a potent immunosuppressive drug, has been clinically used as a rescue therapy for acute graft rejection. However, DSG has severe adverse effects that limits its use. Here, we examined the optimized therapeutic protocol for DSG using chronopharmacological profiles of it. METHODS: First, a dosing time-dependent difference in the toxicity and efficacy of DSG was determined using a heterotopic heart transplantation model. Second, chronokinetics of DSG were examined to reveal the mechanism for dosing time-dependent differences in the effect. RESULTS: In rats treated with DSG at the active period, bone marrow suppression and damage of small intestine were significantly severe. However, no significant difference was found in cardiac allograft survival and pharmacokinetics according to the timing of drug administration. CONCLUSIONS: The toxicity of DSG varied with the dosing time, whereas its efficacy did not. The chronopharmacological approach may provide merits for immunosuppressive therapy with DSG in clinical organ transplantation.

Versatility of the inferior epigastric artery as an interpositional vascular graft in living-related liver transplantation.

We have used the recipient inferior epigastric artery as an interpositional vascular graft in living-related liver transplantation cases with hepatic artery obstruction, enabling us to restore the arterial inflow sufficiently to the transplanted liver. The inferior epigastric artery is easy to access during abdominal surgery. Easy to harvest, it is anatomically constant and has a caliber equivalent to that of the hepatic artery. Donor site morbidity is negligible. There is no risk of rejection because of the autograft. There has been no report on the availability of the inferior epigastric artery for hepatic artery reconstruction. We consider this vessel as a good option for an arterial conduit in case of the inadequacy or thrombosis of the hepatic artery in living-related liver transplantation.

A simple method to confirm patency of the graft bile duct during living-related partial liver transplantation.

A bile duct stricture caused by an inadvertent ligation or suture during donor operation is rare, but not a negligible complication after living-related liver transplantation (LRLT). We present here a simple technique to prevent this kind of complication. Before bilioenteric anastomosis, a rod-shaped surgical probe was introduced into the bile ducts of the graft to examine their patency. The position of the surgical probe and the liver segment in which the probe proceeded was checked using ultrasonography. Using this technique in all of our 60 cases of LRLT, we have had no experience of this bile duct complication. We recommend this technique to be adopted in LRLT and split-liver transplantation to diminish the risk of biliary complications.

Portal venoplasty for recipients in living-related liver transplantation.

BACKGROUND: In 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. METHODS: After 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. RESULTS: This new portal venoplasty technique was used in 7 of 28 child cases, and gave good results without thrombosis or other complications. CONCLUSIONS: Our new portal venoplasty technique is useful in LRLT in small children when the recipient or graft PV is not long enough.

Successful hepatic vein reconstruction in 42 consecutive living related liver transplantations.

BACKGROUND: In living related liver transplantation (LRLT), reconstruction of the hepatic vein (HV) by end-to-end anastomosis has been reported to be associated with acute or late outflow block. METHODS: We reviewed 42 patients who underwent LRLT from January 1996 to September 1998. RESULTS: In 7 (27%) of the 26 donor grafts obtained from left lateral segmentectomy or extended lateral segmentectomy and in 9 (56%) of the 16 grafts obtained from left lobectomy, venoplasty was required. In the remaining 26 grafts, 1-orifice left HV was obtained. In addition to the division of the duct of Arantius, the left inferior phrenic vein was divided routinely in 16 patients, which contributed to reducing the venoplasty rate from 46% to 25% (P =.1704). In all 42 patients, HV was reconstructed successfully by end-to-end anastomosis. The median ratio of the diameter of the recipient's HV to that of the graft's HV was 1.2 (range, 0.8-2.1). The grafts were fixed to the abdominal wall by using the falciform and round ligaments at a site where Doppler ultrasound showed sufficient flow in the respective vessels. Three patients developed late-onset HV obstruction and required balloon dilatation either by means of a venous route or a transhepatic route: 1 patient received a new liver on the 232nd postoperative day, 1 patient died of sepsis without outflow block, and the last patient is doing well. CONCLUSIONS: In LRLT, the division of the duct of Arantius and the left inferior phrenic vein followed by extensive clamping of the common trunk contributed to obtaining a 1-orifice HV. This facilitates anastomosis of the HVs of the grafts to the recipients' HVs, and fixation of the grafts by using the falciform and round ligaments prevents rotation of the grafts and subsequent acute outflow block.

Donor hepatectomy for living related partial liver transplantation.

BACKGROUND: An essential prerequisite for living related partial liver transplantation is to perform donor hepatectomy with minimal risk while preserving graft viability. This article describes a safe method of donor hepatectomy that was used for five patients who underwent living related liver transplantation. METHODS: Liver parenchymal transection was performed by the selective vascular occlusion technique in four patients, and interruption of the blood supply to the left medial segment was carried out along the right side of the umbilical portion before parenchymal division in the other patient. RESULTS: These procedures resulted in insignificant intraoperative blood loss, for which no banked blood or blood derivatives were transfused. The postoperative course for each of the five donors was uneventful, and excellent graft viability was verified by the fact that the five recipients showed a good immediate postoperative course without marked increases in the serum activities of liver enzymes. CONCLUSIONS: We believe that the operative risk of living related donor hepatectomy is minimal if it is performed by experienced liver surgeons with the present procedures.

Electric activity and motility in the side-to-side isoperistaltic ileal reservoir.

Twelve dogs underwent total colectomy and ileorectal anastomosis with construction of a side-to-side isoperistaltic ileal reservoir 20 cm long. The average stool frequency was 18 per 24 hours within the first two weeks after operation, decreasing to five per 24 hours at eight weeks. Stool consistency was liquid at two weeks, becoming semisolid at eight weeks. Saline absorption from a normal segment of ileum 20 cm long was 29 mL/hr. The average saline absorption from the reservoir was 74 mL/hr at four weeks and 106 mL/hr at eight weeks. The average volume of a 20-cm segment of ileum with an intraluminal pressure of 10 cm H2O was 69 mL. The average reservoir volume with the same intraluminal pressure immediately after construction was 203 mL, increasing to 458 mL at eight weeks. Frequency of slow electric waves in the normal canine ileum was 15.71/min, which decreased to 10.21/min immediately after construction of the reservoir. By eight weeks, the slow waves increased to 13.51/min. It appears that electric activity in the muscle of the isoperistaltic lateral ileal reservoir returns to near normal eight weeks after operation. Enlargement of the reservoir in the absence of severe distention does not appear to interfere with peristaltic activity. Stool frequency is reduced simultaneously when peristaltic activity returns and the reservoir enlarges.

Development of intrahepatic cholelithiasis long after primary excision of choledochal cysts.

BACKGROUND: Biliary stricture with dilatation is a putative cause of intrahepatic bile duct stones. However, this hypothesis has never been proved. STUDY DESIGN: Fifty-six patients had operative cholangiography, underwent standard excision of a choledochal cyst, and were reviewed at follow-up clinics at a mean follow-up time of 13 years and 6 months. The incidence of complications such as intrahepatic cholelithiasis was analyzed according to the morphologic types of the intrahepatic bile ducts as observed at the initial operation. RESULTS: Group 1 patients (29 cases) did not show any dilatation of the intrahepatic bile ducts. Intrahepatic cholelithiasis developed in only one case (3 percent). In group 2 (24 cases), the intrahepatic bile ducts were dilated but not associated with any downstream stenosis. One patient (4 percent) suffered from intrahepatic cholelithiasis. Group 3 patients (3 cases) had dilatation of the intrahepatic bile ducts associated with downstream stenosis, and none of them was free from the development of intrahepatic biliary stones (3 cases). CONCLUSIONS: Patients with biliary dilatation with stricture of the intrahepatic bile ducts are most likely to develop intrahepatic cholelithiasis after surgical excision of a choledochal cyst, and their stenosis should be relieved by whatever means feasible at initial operation.

Small-for-size grafts in living-related liver transplantation.

BACKGROUND: The problems associated with small-for-size grafts in living-related liver transplantation are not fully understood. STUDY DESIGN: A consecutive series of 79 patients underwent 80 living-related liver transplantation procedures, including one retransplant, at the University of Tokyo from January 1996 to January 2000. They were divided into two groups by graft size: graft weight/recipient standard liver volume ratios of 40% or less (n = 24), and more than 40% (n = 56). Preoperative status, mortality, morbidity, duration of hospital stay, and postoperative graft function were examined and compared between the groups. RESULTS: The rate of patients who were restricted to the intensive care unit preoperatively was comparable between the groups (33% versus 21%, p = 0.27). The mean standard liver volume ratios were 37% in the small graft group and 84% in the large group. Survival rates were 80% (5 of 24) for the small graft group, which was significantly lower than that for the large group (96%, 54 of 56, p = 0.02). The rate of acute rejection was comparable between the groups (33% versus 43%, p = 0.47). Vascular complication was observed in 17% of the small graft group patients and 23% of the large group (p = 0.77). No difference was observed in the frequency of bile leakage or bile duct stenosis (25% versus 21%, p=0.77). Hyper-bilirubinemia and elongation of prothrombin time persisted longer in the small graft group than in the large group (p < 0.0001 for both). CONCLUSIONS: Our surgical results may suggest that a graft weight ratio of 40% or less provides a lower chance of survival after living-related liver transplantation.

Survival of rats undergoing continuous bile drainage depends on maintenance of circadian rhythm of bile secretion.

It is very difficult to collect bile secretions from animals for extended periods of time. We compared the use of saline or water as drinking fluids to sustain the animals, which were being continuously drained of bile. Complete bile drainage was performed in 16 male Wistar rats by surgical intervention. After surgery, 8 rats were given tap water, and the other 8 were given normal saline for water. The rats that received water rapidly lost weight after bile drainage, and all died within 8 days after the operation. In contrast, all rats that drank saline maintained their body weight and survived 14 days or longer after surgery. Serum biochemistry of the rats with water intake on the third day after bile drainage revealed hyponatremia, hypochloremia, and acute renal failure resulting in hyperkalemia. In contrast, electrolyte balance and renal function were normal in the rats with saline intake, and bile was secreted continuously with a circadian rhythm. These results clearly demonstrate that saline as drinking water is essential to the replacement of lost fluids and loss of electrolytes due to bile drainage. Further, saline proved efficacious for sustaining experimental animals undergoing continuous bile collection.

Reduction of intestinal adhesions by postoperative peritoneal irrigation with dialysis solution.

In a canine experimental model in which intestinal adhesions were created by exposing the intestine to talc powder and autologous blood, the incidence of adhesion formation and the severity of adhesions were reduced tenfold when the abdominal cavity was irrigated with peritoneal dialysis solution three times daily for 4 days postoperatively. The mechanism of peritoneal dialysis solution in reducing the severity of adhesion appears to be related to the mechanical factors of washing out debris from the abdominal cavity, although it may also have a fibrinolytic effect. Long-term use of peritoneal dialysis solution may alter systemic fluid and electrolyte imbalance. Placing a small peritoneal dialysis catheter in the abdominal cavity at the conclusion of major abdominal operations and subsequent daily irrigation with peritoneal dialysis solution may be a helpful adjunct in reducing the incidence of postoperative adhesions.

Partial liver transplantation from living related donors.

Living related liver transplantation was performed in five cases between June 1989 and July 1991 at Shinshu University Hospital. All of the donors were fathers of the patients and blood type was identical in each case. All of them were discharged from the hospital 2 weeks after hepatectomy without any complications. They started to work 2 months after surgery. Four recipients are surviving but one died. Three are enjoying daily life 17 months after LT in case 1, 5 months after LT in case 4, and 4 months after LT in case 5. Case 2 is still in the hospital 14 months after LT. Advantages of LRLT we noted were (1) cases can be performed totally electively and allow full preparation for the family and the transplant team, (2) primary graft nonfunction has not been observed to date, and (3) 38 patients received the chance of liver transplantation in their own country, which under current legislation would not otherwise have been possible. Disadvantages of LRLT were (1) partial hepatectomy was performed in healthy persons, and (2) retransplantation is difficult.

Cystic dilatation of the intrahepatic biliary system in biliary atresia after hepatic portoenterostomy.

Five cases of intrahepatic biliary cyst or cystic dilatation and one suspicious case were found (6.4%) among 93 survivors of biliary atresia. The age at manifestation of such cysts ranged from 6 months to 12 years. These cysts or cystic dilatations were treated surgically in two cases, by percutaneous transhepatic cholangiodrainage (PTCD) in two, and not treated in one. Four patients are alive; one died of biliary atresia. Twenty-nine well-documented cases of intrahepatic biliary cyst were found in the literature, including five treated by the authors. The modes of dilatation were as follows: type A, noncommunicating cyst; type B, cyst with tiny communication with the intestinal loop; and type C, cystic dilatation. Clinical symptoms were fever, jaundice, acholic stool, and "cholangitis." Nineteen patients (66%) had symptoms within 4 years after the Kasai operation (first group); the modes of dilatation were mostly types A and B. However, in five of six patients with type C dilatation, symptoms developed after 10 years of age (second group). The prognosis for the second group appears poor because the condition of the liver worsens once cystic dilatation develops.

The effects of administering hyperalimentation solutions into the atrium and pulmonary artery.

Pulmonary hypertension, edema, and congestion have been found in three infants who died after infusion of chronic TPN solutions through catheters placed into the right atrium (RA) or pulmonary artery (PA). In 24 anesthetized dogs receiving varying concentrations of dextrose and water through catheters placed into the RA, the endothelium of the RA evidenced injury only when concentrations of 20% DW or greater were infused. Both the main PA and distal PA endothelium showed evidence of injury only when concentrations higher than 40% DW were infused. When solutions were infused directly into the main PA, the main PA endothelium revealed injury if more than 15% DW was infused, and the distal PA showed moderate endothelial injury when 10% DW or greater was infused. The distal PA evidenced more severe endothelial injury after concentrated dextrose solution infusion than either the RA or main PA. Pulmonary congestion, edema, and hypertension became increasingly prominent when 24-hour infusions of 10% DW or more were placed into the main PA, or concentrations higher than 40% were infused into the RA. Distal PA endothelial injury appears to correlate directly with the severity of pulmonary congestion, suggesting endothelial cell emboli.