Modified triangular hepatic vein reconstruction for preventing hepatic venous outflow obstruction in pediatric living donor liver transplantation using left lateral segment grafts.

HVOO can be a critical complication in pediatric LDLT. The aim of this study was to evaluate a modified triangular technique of hepatic vein reconstruction for preventing HVOO in pediatric LDLT. A total of 298 pediatric LDLTs were performed using a left lateral segment graft by 2 methods for reconstruction of the hepatic vein. In 177 recipients, slit-shaped anastomosis was indicated with partial clamp of the IVC. A total of 121 recipients subjected to the modified triangular anastomosis with total clamp of the IVC. We compared the incidence of hepatic vein anastomotic complications between these 2 methods. Nine of the 177 cases (5.3%) treated with the conventional technique were diagnosed with outflow obstruction. All 9 cases underwent hepatic vein reconstruction with the slit-shaped hepatic vein anastomosis. In contrast, there were no cases of outflow obstruction in the 121 cases treated with the modified triangular anastomosis. The modified triangular technique of hepatic vein reconstruction with total clamping of the IVC was useful for preventing HVOO in pediatric LDLT.

A severely cholestatic liver graft can be successfully used in deceased donor liver transplantation.

The shortage of deceased organs is still a serious issue in Japan. A proactive approach to using liver grafts from extended criteria donors (ECDs) may be one way of expanding the donor pool; however, if it is recklessly attempted, a recipient receiving such a marginal graft can be at risk of mortality due to primary non-function or delayed graft function. We herein report the successful outcome of a recipient receiving a severely cholestatic graft that was considered transplantable because it lacked features characteristic of a long duration of "cholestasis" according to the precise interpretation of a donor biopsy. Plasma exchange was intentionally introduced to prevent toxic insult by hyperbilirubinemia immediately after transplant. Despite transient acute kidney injury immediately after transplant, the patient's renal impairment was well managed with a renal-sparing immunosuppressive regimen consisting of basiliximab and mycophenolate mofetil. Although the use of liver grafts from ECDs still needs to be discussed, especially regarding graft selection and allocation policies, efforts not to discard valuable grafts should be undertaken in our country.

Optimizing hepatic venous outflow reconstruction for hepatic vein stenosis with indwelling stent in living donor liver retransplantation.

The patient was a boy of 7 years and 5 months of age, who underwent LDLT for acute liver failure at 10 months of age. HV stent placement was performed 8 months after LDLT because of intractable HV stenosis. At 7 years of age, his liver function deteriorated due to chronic rejection. The patient therefore underwent living donor liver retransplantation from his father. The HV was transected with the stent in situ. The IVC was resected due to stenosis. The pericardial cavity was opened and detached around the IVC to elongate the IVC. The divided ends of the IVC were joined by suturing to the posterior wall of the IVC. A new triangular orifice was made by adding an incision on the anterior wall of the IVC. The graft HV was then anastomosed to the new orifice with continuous sutures in the posterior wall and interrupted sutures in the anterior wall using 5-0 non-absorbable sutures. Doppler ultrasound showed a triphasic waveform. We successfully performed HV reconstruction without a vascular graft. This is a feasible procedure for overcoming HV stenosis in LDLT patients with an indwelling stent.

[OPERATIONAL EXPERIENCE OF AUTOMATIC POSTING SYSTEM TO THE NATIONAL CLINICAL DATABASE USING FILEMAKER PRO].

We would like to introduce a semi-automated registration system for the National Clinical Database. Japan Surgery Society runs the National Clinical Database since January 2011. And automated registration system is long-awaited due to the number of cases and diverse items to register. Well-known database management system, FileMakerPro enabled collecting and registering the items to the web-site automatically. Still some items need to copy one by one, but after filling the data, all data would be input to the web page for registration. Merit for this automated system is increasing not only the efficiency of administration work but the quality and the usefulness of this database. This paper is to report the outline of the registration system to the NCD database.

Anatomical Resection of the Bile Duct: A Hidden Door to the Bile Duct.

BACKGROUND/AIMS: Pancreas-preserving resection of the bile duct has been attempted as an organ preserving procedures for the treatment of low-grade malignant neoplasms of the bile duct. The fact that the lower bile duct penetrates pancreas head to join the duodenum, makes those attempts one of the challenging procedures in biliary tract surgery. Here we present a novel and unique surgical technique for anatomically resecting lower bile duct, focusing on the anatomy of the pancreas head. METHODOLOGY: A patient with middle bile duct cancer underwent this procedure. Subsequent to Kocher's maneuver, pancreas head was dissected from the posterior side of the duodenum that was a key step to recognize the embryological fusion plane between the anterior and the posterior pancreatic segments. Along this fusion plane pancreas head was able to be divided and the covering pancreatic parenchyma was split open to expose the whole intrapancreatic bile duct. RESULTS: The patient had no signs of pancreatic fistula and post-operative course was uneventful. Negative surgical margins were obtained thanks to the presented technique. CONCLUSIONS: This procedure might be applicable for the treatment of bile duct neoplasms, in case of lesions spread to the lower bile duct. Otherwise that might require pancreatoduodenectomy.