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.

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.

Multi-modal optimization of bismuth vanadate photoanodes via combinatorial alloying and hydrogen processing.

Alloying transition metals, such as Mo, into BiVO4 has emerged as the primary mechanism for improving carrier transport in this photoanode for solar fuels production. The present work establishes the generality of improving photoelectrochemical performance through co-alloying with a transition metal electron donor and a structure-modulating rare earth. Further improvement for all such alloys is obtained by annealing the oxide materials in H2, ultimately producing photoanodes with above 3 mA cm-2 photocurrent density under AM 1.5G illumination, in the top tier of compact BiVO4 films.

Quadrics and Scherk towers.

We investigate the relation between quadrics and their Christoffel duals on the one hand, and certain zero mean curvature surfaces and their Gauss maps on the other hand. To study the relation between timelike minimal surfaces and the Christoffel duals of 1-sheeted hyperboloids we introduce para-holomorphic elliptic functions. The curves of type change for real isothermic surfaces of mixed causal type turn out to be aligned with the real curvature line net.

A program of training in chemical pathology for residents in pathology.

We have developed a new program of instruction in chemical pathology for residents in pathology. The major features that differentiate this program from its predecessor are: first, an emphasis on principles rather than technical details of biochemical analysis; second, didactic instruction and practical experience in laboratory management and administration; and, third, instruction in interpretation and selection of laboratory tests. The organization, content, instructional approaches and learning objectives are described.

Heterogeneity of serum creatine kinase activity among racial and gender groups of the population.

To develop reference ranges for creatine kinase (CK) appropriate for the patient population served by this hospital, levels of serum CK were measured in 1,537 individuals in our employee population. There was substantial heterogeneity in mean, median, and range of CK levels among the several race/gender subgroups in the population studied. The race/gender subgroups could be placed into three broad groups: a high CK group, composed solely of black men; an intermediate CK group, consisting of nonblack men plus black women; and a low CK group, comprised of nonblack women. Mean CK level of the high CK group was twice that of the intermediate CK group, which, in turn, was twice that of the low CK group. Differences in mean CK values among the subgroups placed into either the intermediate CK group or the low CK group were not significant when tested with analysis of variance. Therefore, practical reference ranges for these groups are as follows: 52-520 U/L for the high CK group; 35-345 U/L for the intermediate CK group; and 25-145 U/L for the low CK group.

Efficacy of double-filtration plasmapheretic cross-circulation with a high-permeability membrane using canine harvested liver in porcine fulminant hepatic failure model.

INTRODUCTION: The use of bioartificial liver devices requires. A sufficient liver cell mass to provide adequate metabolic support, reduction of xenogeneic immune reactions, and avoidance of viral transmission. We have developed a plasmapheresis system using a semipermeable membrane combined with canine whole liver perfusion (PMCWLP). In this study, we investigated the efficacy of our system in a porcine fulminant hepatic failure (FHF) model. METHODS: The porcine FHF model was established by intraportal administration of alpha-amanitin (0.1 mg/kg) and lipopolysaccharide (1 microg/kg). Nine hours after drug injection, xenogenic perfusion treatment was performed twice within 6 hours (n = 5). As the plasmapheresis device, we used a hollow-fiber module with cellulose diacetate porous fibers (pore size, 0.05 microm, surface area, 2 m2). The canine whole liver was perfused with modified Krebs solution, which is commonly used in many laboratories, containing albumin (2 g/dL) and glucose (300 mg/dL). Control pigs (n = 10), had the circuit not connected to the whole canine liver. RESULTS: The survival of FHF pigs was significantly increased by the treatment (58.9 +/- 21.8 hour) compared with the controls (22.3 +/- 8.1 hour). Mean blood ammonia levels and intracranial pressure during treatment were significantly lower compared with control groups. CONCLUSION: Treatment of FHF pigs with the system significantly increased survival time, suggesting that this method may have applications as a clinical liver assist device.

In vitro evaluation of cross-circulation system using semipermeable membrane combined with whole liver perfusion.

INTRODUCTION: Many types of isolated hepatocytes-based bioartificial liver have been developed. However, to maintain hepatocyte-specific functions for a long period is still a significant challenge. The possibilities of rejection or viral transmission still remain as untackled obstacles. We developed a cross-circulation system, using a semipermeable membrane combined with whole liver perfusion. Detoxifying functions of the extracorporeal porcine liver and molecular movements across the membrane were evaluated in vitro. METHODS: The hollow-fiber module has a molecular cutoff of 100 kD. A spiked solution containing 500 mL low molecular dextran solution spiked with 12 mg ammonium chloride, 500 mg D-galactose, and 300 mg lidocaine, which mimicked a patient, was recirculated through the inner fiber space. The extracorporeal liver perfusion circuit consisted of an extra-fiber spaces. A reservoir containing 1000 mL healthy pig plasma, a membrane oxygenator, and a porcine whole liver. Both circuits circulated in the opposite direction for 6 hours. RESULT: In 6 hours, 47.3% +/- 10.2% of ammonia, 89.5% +/- 1.7% of D-galactose, and 95.5% +/- 1.0% of lidocaine were eliminated from the circuits; 66.5 +/- 11.1 mg of urea were produced at the same time. Oxygen consumption was maintained between 0.248 and 0.259 mL/100 g liver/min for 6 hours. Movement of IgM was completely blocked by the 100-kD membrane, whereas albumin was freely transferred from the reservoir to the intrafiber space. CONCLUSION: The perfusion experiments showed the possibility of using a whole liver with oxygenated plasma perfusion in a bioartificial liver system in vitro.

Intraoperative blood lactate level as an early predictor of initial graft function in human living donor liver transplantation.

UNLABELLED: This study was performed to investigate whether intraoperative changes in blood lactate levels after hepatic allograft reperfusion reflect initial graft function in living donor liver transplantation (LDLT). PATIENTS AND METHODS: From 1994 to 2003, 15 of LDLT cases were divided into two groups based on the intraoperative blood lactate levels. Group A consisted of seven recipients whose new liver grafts started to consume lactate immediately after portal perfusion. Group B consisted of the remaining eight recipients whose intraoperative blood lactate values showed no change or an elevation for 2 hours after graft revascularization. RESULTS: All Group A patients survived, whereas three out of eight patients in Group B died of infection and portal vein thrombosis within 3 months after LDLT. There was no significant difference in preoperative donor and recipient laboratory data. The recipient age and body size in Group B were significantly higher than those in Group A, indicating that Group B consisted of small-for-size liver transplant cases. Serum total bilirubin concentrations in Group B were significantly higher than Group A from postoperative day 5 to 23, whereas postoperative liver enzyme levels and prothrombin time were similar between the two groups. CONCLUSION: The change in intraoperative blood lactate after hepatic allograft reperfusion served as an accurate predictor of initial graft function which was associated with graft size in human LDLT.

Attenuation of canine warm ischemic small bowel injury by novel combination of nitric oxide donor, FK409, and cytokine suppressive anti-inflammatory agent FR167653.

Organ ischemia-reperfusion injury is caused by two consecutive steps, microcirculatory disturbance and neutrophil-endothelial cell interactions, which are caused by inflammatory cytokines. We examined the hypothesis that combination therapy with a donor (FK409) of nitric oxide, one of the potent mediators with diverse roles as a vosodilator and a platelet inhibitor, together with the cytokine suppressor agent (FR167653) attenuates warm ischemic injury in canine small bowel. Small bowel ischemia was initiated by clamping the superior mesenteric artery and vein. Animals were divided into two groups: a control group (n = 5) subjected to 2-hour small bowel ischemia only, and a combination therapy group (FK/FR group, n = 5) that received FK409 (300 mcg/kg/h) plus FR167653 (1 mg/kg/h) intravenously before and after the ischemic event. We evaluated animal survival, small bowel tissue blood flow, and enzyme release from the small bowel. All controls died from severe acidosis within 2 days and all the FK/FR animals survived 7 days (P < .05). The FK/FR group recovered more than 70% of blood flow immediately after the revascularization, while the flow was less than 40% among the controls. Serum creatine phosphokinase values in the control group after reperfusion were significantly higher than those in the FK/FR group. In conclusion improvement of the microcirculation by FK409 and inhibition of cytokine release by FR167653 together attenuated warm ischemic small bowel injury.

G-CSF producing malignant fibrous histiocytoma in the jejunum: a case report.

Malignant fibrous histiocytoma arising from the alimentary tract is extremely rare. We experienced a young patient with an inflammatory type of malignant fibrous histiocytoma in the jejunum which produced granulocyte-colony stimulating factor. A 16-year-old male was admitted to Umehara Hospital with abdominal pain, frequent vomiting of 2 days' duration, high fever and leukocytosis. Serum level of granulocyte-colony stimulating factor was 61.2 pg/mL. Plain abdominal X-ray, ultrasonography and computed tomography led to the diagnosis of intussusception with small intestinal tumor. On the 2nd hospital day, the patient underwent exploratory laparotomy. The jejunum showed intussusception with a hen's egg-sized tumor. After manual reduction, a 20-cm segment of the jejunum was removed. The patient was alive and doing well 29 months after the operation. Microscopic examination of the resected tumor disclosed an inflammatory type of malignant fibrous histiocytoma in the jejunum, and immunohistochemistry was positive for granulocyte-colony stimulating factor. This is the 5th case of malignant fibrous histiocytoma arising from the small intestine that has been described in the English literature.

Long-term results of modified distal splenorenal shunts for the treatment of esophageal varices.

BACKGROUND/AIMS: Long-term results were compared for 3 types of distal splenorenal shunt for the treatment of esophageal varices. METHODOLOGY: Between July 1983 and December 1997, 45 patients with esophageal varices underwent distal splenorenal shunt. Group 1 underwent standard distal splenorenal shunt (n = 11). Group 2 underwent distal splenorenal shunt with splenopancreatic disconnection (n = 11). Group 3 underwent distal splenorenal shunt with splenopancreatic disconnection and gastric transection (n = 23). RESULTS: Additional treatment for recurrent varices was required in group 1, (n = 1, 9.1%), group 2 (n = 2, 18.2%), and group 3 (n = 1, 4.3%). All of the patients with recurrent varices developed a shunt stenosis within the 1st year after distal splenorenal shunt. The prevalence of hyperammonemia in group 1 was 40.0% at 1, 5, and 10 years. In group 2, the prevalence was 14.3% at 1 year, 31.4% at 5 years, and 54.3% at 10 years. In group 3, the prevalence was 0% at 1 year, and 9.1% at 5 and 10 years. The differences between group 3 and groups 1 and 2 were significant (P < 0.01). The cumulative survival rates at 1 year were 90.9%, 63.6%, and 95.7% for groups 1, 2, and 3, respectively. At 10 years, the cumulative survivals rates were 70.7%, 63.6%, and 69.4% for groups 1, 2, and 3, respectively. There were no significant differences in survival between the 3 groups. CONCLUSIONS: Distal splenorenal shunt with splenopancreatic disconnection and gastric transection may reduce the incidence of postoperative hyperammonemia.

Treatment of spontaneous ruptured hepatocellular carcinoma.

BACKGROUND/AIMS: Spontaneous rupture with bleeding is a potentially life-threatening complication of hepatocellular carcinoma (HCC). We review our experience with treatments of ruptured HCC. METHODOLOGY: Between January 1988 and December 1997, 18 patients with ruptured HCC were admitted. The patients were divided into 4 groups according to the treatment type of ruptured HCC. Group 1 consisted of 10 patients treated by transarterial embolization (TAE) followed by elective hepatectomy. Group 2 consisted of 2 patients treated by only TAE. Group 3 consisted of 3 patients treated by emergency operation. Group 4 consisted of 3 patients who could not be treated by TAE or surgery. RESULTS: In Group 1, 4 of the 10 patients died; 3 from recurrent HCC and 1 from cerebral hemorrhage, and hospital mortality was absent. The 1-year survival rate was 87.5%. In Group 2, both patients recovered sufficiently well to be discharged. The 1-year survival rate was 50%. In Groups 3 and 4, hospital mortality rate was 100%. CONCLUSIONS: TAE followed by elective hepatectomy was an effective treatment in patients with ruptured HCC.

Hepatocellular carcinoma responding to chemotherapy with 5-FU.

A 69-year-old man with unresectable hepatocellular carcinoma and portal vein tumor thrombus was treated by chemotherapy with 5-fluorouracil. A dose of 500 mg/day of 5-fluorouracil was continuously administered via a central venous catheter. After 4 months, the alpha-fetoprotein level was decreased from 50,000 ng/mL to 4,760 ng/mL. Computed tomography revealed disappearance of the low-density area in the liver parenchyma, but the portal vein tumor thrombus was not changed. After 6 months, pancytopenia appeared and continuous infusion of 5-fluorouracil was stopped. After 8 months, the patient died of pneumonia, at which time the alpha-fetoprotein level was 12,000 ng/mL. Continuous intravenous infusion of 5-Fluorouracil was effective against unresectable primary hepatocellular carcinoma, but had little influence on portal vein tumor thrombus.

[Measurement of small quantities of alpha 2-macroglobulin in bronchoalveolar lavage fluid by enzyme-labelled immunoassay, and its clinical implication in pulmonary disease].

We established an enzyme labelled immunoassay for the determination of alpha 2 macroglobulin (alpha 2M). The assay range was from 2 to 140 ng/ml and the within-assay coefficient of variation (CV) were 5.2% at 31.2 ng/ml and 6.4% at 62.5 ng/ml. Between-day CV ranged from 6.9% to 15.4%. Using this method, alpha 2 M was determined in the bronchoalveolar lavage fluid (BALF) from patients with interstitial lung diseases. Those diseases were active and inactive sarcoidosis, hypersensitivity pneumonitis and idiopathic pulmonary fibrosis (IPF, including collagen disease). We divided the IPF patients into two groups, 'acute type' and 'chronic type', judging from the prognosis. alpha 2 M/Albumin ratio in BALF in the active sarcoidosis and acute type IPF groups is significantly higher than that in the inactive sarcoidosis and chronic type IPF. These findings suggest that alpha 2 M in BALF can be a sensitive marker of the interstitial lung disease.

[The effects of human urine on the adhesion of calcium oxalate crystal to renal tubular cells].

PURPOSE: We examined the effects of human urine on the adhesion of calcium oxalate monohydrate (COM) crystals to Madin-Darby canine kidney (MDCK) cells in vitro. METHODS: Quantitative assay of COM crystal adhesion to MDCK cells: MDCK cells were exposed to COM crystal suspension for 5 minutes. Various urine samples were added in the COM crystal suspension. The adherent COM crystals on the MDCK cells were dissolved by 5 N hydrochloric acid. Calcium concentration of the solution was measured by atomic absorption analysis to quantify the volume of adherent COM crystals. This assay was applied for the experiments as follows. (1) Effect of human urine on COM crystal adhesion. (2) To investigate whether human urine inhibited COM crystal adhesion by acting on the crystal surface or on the cell surface. (3) Isolation of the substance from human urine that inhibits COM crystal adhesion. (4) Comparison of the inhibitory activities of the urine between from stone formers and healthy controls. RESULTS AND CONCLUSION: (1) Human urine had a strong inhibitory effect on COM crystal adhesion to MDCK cells. (2) The capacity of human urine to inhibit adhesion of COM crystals to MDCK cells was shown to be mediated by their ability to act on the crystal surface. (3) We isolated a macromolecular fraction (MW 60,000) that had strong capacity to inhibit cellular adhesion of COM crystals through ion exchange and gel filtration chromatography. (4) Nine urine samples from stone formers demonstrated extreme low inhibitory activities, which supposed us that the inhibitory capacity of the urine against crystal adhesion might be one of the risk factors in kidney stone formation.