Heterotopic pancreas autotransplantation with spleen for uncontrollable hemorrhagic pseudocyst and disabling pain in chronic pancreatitis.

BACKGROUND/AIMS: In this study, we report on a heterotopic segmental pancreatic autotransplantation (HPAT) with spleen for alcoholic chronic pancreatitis with uncontrollable hemorrhagic pseudocyst and complete portal venous obstruction. The patient was a 72-year-old man who had an alcoholic chronic pancreatitis with severe abdominal pain and hemorrhagic pseudocyst. The first bleeding from a pseudoaneurism of the gastro-duodenal artery (GDA) to the cyst of pancreas head was stopped by interventional radiology (IVR) at our hospital on May 2010. The second bleeding happened with severe abdominal pain on February 15th, 2011; he was admitted on February 17. The IVR was not successful. METHODOLOGY: There were two problems for the operation. The first was the severe inflammation and the second was the control of hemorrhage from GDA. We were afraid of the postoperative hemorrhage due to the leakage of pancreatic juice in the pancreato-duodenectomy (PD). Therefore, we chose the HPAT as a solution for postoperative hemorrhage and severe abdominal pain. After complete duodeno-pancreatectomy with spleen, we performed HPAT with spleen on March 8, 2011. The pancreatic duct reconstruction was performed by Roux-en-Y anastomosis to the jejunum. RESULTS: The postoperative course was uneventful. The abdominal pain had resolved completely and the patient remained normoglycemic after HPAT. CONCLUSIONS: We conclude that HPAT is a useful option for hemorrhagic pseudocyst of the pancreas head with severe abdominal pain of chronic pancreatitis.

Perioperative immunological differentiation in liver cirrhotic patients who underwent living related liver transplantation.

BACKGROUND/AIMS: Liver cirrhotic patients are immunological compromised hosts. Preoperative status in cirrhotic patients affects postoperative infection complications. This study investigates the perioperative immunological changes in the differentiation by MELD score. METHODOLOGY: Fifteen patients underwent LDLT and were divided two groups, Group I (n=5, MELD score >=20) and Group II (n=10, MELD score <20). Immunological status of cirrhotic patients was analyzed for Th1, Th2, Treg and Th17 by flow cytometry using monoclonal antibody CD3/CD19,CD4/8, FoxP3, IL-17, IFN-γ and TNF-α. RESULTS: T cell decreased and increased gradually following LDLT. The preoperative T cell count of MELD score 33 patients was very low. CD4 and CD8 T cells also decreased after LDLT. The preoperative CD8+ T cell count of MELD score 33 patients was very low. Th17 decreased and recovered gradually in the all patients after LDLT. However Th17 of MELD score 33 did not recover. IFN-γ-producing cells in naive T cells decreased after LDLT. Preoperatively those in the Group I was lower than those in the Group II. The population of Treg decreased in the Group I, however, it increased in the Group II on 7 days after LDLT. CONCLUSIONS: The patients with MELD score >20 showed a decrease of cytotoxic immunity with both diminution and delay of CD8+ T cells and Th17 helper T cells. The cytotoxic immunity of the patients with MELD score <20 was maintained and recovered in the early period after LDLT. The patients with MELD score >20 might be at high risk of infection after LDLT.

Catheter-directed continuous thrombolysis following aspiration thrombectomy via the ileocolic route for acute portal venous thrombosis: report of two cases.

Although acute portal venous thrombosis (PVT) is a potentially life-threatening complication that occurs after hepatobiliary surgery with portal vein (PV) reconstruction or splenectomy, no effective or universal treatments have yet been established. Transjugular or transhepatic catheter-directed thrombolysis has recently been reported to be effective for treating acute PVT. However, the efficiency of this treatment for complete PV occlusion might be limited because a poor portal venous flow prevents thrombolytic agents from reaching and dissolving thrombi. Moreover, the use of the transjugular or transhepatic route might not be suitable in patients who have undergone major hepatectomy or in those with ascites due to an increased risk of residual liver injury or intra-abdominal bleeding following puncture to the residual liver. We herein describe the cases of two patients with almost total PV occlusion caused by massive thrombi that formed after hepatobiliary surgery, who were successfully treated with catheter-directed continuous thrombolysis following aspiration thrombectomy via the ileocolic route. This treatment should be considered beneficial for treating selected patients such as the two patients described herein.

Successful laparoscopic division of a patent ductus venosus: report of a case.

Patent ductus venosus (PDV) is a rare condition of a congenital portosystemic shunt from the umbilical vein to the inferior vena cava. This report presents the case of an adult patient with PDV, who was successfully treated with laparoscopic shunt division. A 69-year-old male was referred with hepatic encephalopathy. Contrast-enhanced CT revealed a large connection between the left portal vein and the inferior vena cava, which was diagnosed as PDV. The safety of a shunt disconnection was confirmed using a temporary balloon occlusion test for the shunt, and the shunt division was performed laparoscopically. The shunt was carefully separated from the liver parenchyma with relative ease, and then divided using a vascular stapler. Portal flow was markedly increased after the operation, and the liver function of the patient improved over the 3-month period after surgery. Although careful interventional evaluation for portal flow is absolutely imperative prior to surgery, a minimally invasive laparoscopic approach can be safely used for treating PDV.

A 10-year experience of shunt surgery for esophago-gastric varices in a single center in Japan.

BACKGROUND/AIMS: We report 10 years' experience of shunt surgeries, and in particular Inokuchi shunt operation, at a single Japanese center. METHODOLOGY: Subjects were 50 patients who underwent shunt surgery, including Inokuchi shunt, distal splenorenal shunt, H-graft shunt, and inferior mesenteric venous-left renal vein shunt from November 1997 to November 2007. These patients were divided into two groups, a selective shunt group and a non-selective shunt group. RESULTS: Surgical duration was significantly longer in the selective group than in the non-selective group (p<0.0001). Blood loss was also significantly larger in the non-selective group (p=0.012). Pre-portal venous pressure did not change significantly after shunting in the selective shunt group. On the other hand, it decreased significantly from 378 +/- 39.7 mmH2O to 246 +/- 56.0 mmH2O (p<0.0001) in the non-selective group. The 2 and 5 year patency rates were 87% and 68%, respectively, in the selective shunt group, and 87% and 87% in the non-selective shunt group. CONCLUSIONS: Our data on survival rate and shunt patency for Inokchi shunt are similar to those originally reported by Inokuchi in 1984. The consecutive experiences of shunt operation in a single center were important for the improvement of surgical skills, both of the individual surgeon and the team.

A new technique of lateral approach for laparoscopy-assisted donor left hepatectomy.

This report describes laparoscopy-assisted donor left hepatectomy preserving the caudate lobe (LADLH), and a new technique for hand-assisted liver transection between the left lobe and the caudate lobe beforehand, called the 'lateral approach.' Four donor patients underwent LADLH. Preoperative computed tomography investigated the depth and width between the left lobe and the caudate lobe from the Arantius duct. LADLH was performed through a 9cm midline epigastric hand-port incision with four ports. The confluence of the middle and left hepatic veins was encircled with tape. Hand-assisted liver transection between the left lobe and the caudate lobe was performed using laparosonic coagulating shears after precoagulation with radio frequency ablation under ultrasonographic guidance. Through the hand-port incision, the tape around the middle and left hepatic veins could be passed between the left lobe and the caudate lobe to the porta hepatis. We used the tape toward the end of the parenchymal transection to bring the transection plane closer to the surface. The liver parenchyma was divided at Cantlie's line under direct vision. The graft was extracted through the hand-port incision. All donors underwent LADLH completely without any intraoperative complication. None of the donors required transfusion or re-operation.

Intra portal donor specific antigen transfusion might prevent re-infection of hepatitis C virus after living related liver transplantation in hepatitis C hepatic cirrhosis.

BACKGROUND/AIMS: Re-infection of hepatitis C virus (HCV) is very important for prognosis after liver transplantation of HCV cirrhosis. In the mechanism of re-infection of HCV, the peri-transplant immunity including the immunosuppression must be very important for getting the solution of prevention of its infection. (please rewrite this phrase). In this study, we investigated the influences of intraportal DST for HCV-reinfection after living related liver transplantation (LRLT). METHODOLOGY: The 12 patients, who underwent LRLT for the end-stage HCV liver cirrhosis from 1999 to 2007 in our hospital, were estimated about the influence of intraportal DST for re-infection of HCV. The nine persons of all patients had received the intraportal DST after LRLT. RESULTS: These nine patients could be steroid withdrawn within 2 months. The seven persons of all patients that received intraportal DST were treated with perioperative IFN therapy. Two patients had preoperative interferon-beta therapy. The one patient could obtain SVR. The other patient dropped out for the complications. The four patients had interferon-beta therapy in the acute hepatitis phase. Two patients had it in the chronic hepatitis phase. The one patient mentioned before, had preoperative IFN-beta and dropped out. HCV of the one patients without interferon therapy disappeared spontaneously from 3 months. The HCV disappeared in the 6 patients (66.7%) of all nine patients with intraportal DST after LRLT. The five of six patients were SVR. The patient who got preoperative IFN-beta revealed the macrochimerism of donor type CD56+T cell in the graft liver one month after LRLT. The immunological analysis about the patient, who got a spontaneous disappearance of HCV two months after LRLT, demonstrated that CD56+T cells strongly developed the both FasL and TRAIL expressions. CONCLUSION: In this study, the clinical and immunological findings suggested that intraportal DST might affect for the clearance of HCV by the both host immunity and IFN-ribavirin therapy.

A complete physiological orthotopic living related partial pancreatic transplantation alone with pancreatic duct to duct anastomosis for type I diabetes mellitus.

In this study, we reported a complete solitary living related orthotopic partial pancreatic transplantation (LROPPT) with duct to duct drainage of pancreatic juice. A 29-year old man, who has suffered from type I diabetes mellitus (DM) since age 2, underwent LROPPT on 2007 August 9th. He had hypoglycemia for several times per week. His preoperative hemoglobin A1c (HbA1c) was 8.4%. He has little diabetic complications of 2 degree of nephropathy with albuminuria and slight neuropathy. The donor was a 57-year old his father, whose preoperative 75gOGTT and ivGTT revealed normal pattern. Donor was performed hand-assisted distal pancreatectomy with spleen. Operative time was 5 hours and 18 min and intraoperative hemorrhage was 75 ml. Recipient was explored by upper abdominal L-shaped incision. Distal pancreatectomy with spleen with enough expose of both splenic vein and artery, and main pancreatic duct. Both the splenic vein and the arterial anastomosis was made, thereafter, pancreatic duct to duct anastomosis was made by 6-0 PDS with pancreatic duct stent. The pancreatic duct stent lead to extra abdomen through Papilla Vater and duodenum. Pancreatic tissue was anastomosis by 6-0 prolene using fibrin-glue. After that, absorbed thin mesh was rolled around the pancreatic anastomosis with fibrin-glue. The operative time was 10 hr 10 min and the blood loss was 435 ml. Patient was discharged without a pancreatic leakage and vessel thrombosis 16th days after transplantation. LROPPT is a complete physiologic procedure. In Japan, almost of donor is marginal donor aged above 50 years old. The portal drainage might be comfortable for the stress of the partial pancreatic graft.

[A case of advanced gastric cancer treated with paclitaxel and TS-1].

We treated a case of advanced gastric cancer with paclitaxel and TS-1. A 64-year-old man underwent total gastrectomy, splenectomy, and D2 + No. 16 a 2, b 1 lymph node (LN) dissection for gastric cancer. Computed tomography (CT) revealed metastases of supraclavicular and para-aortic LNs in the 4th postoperative month. Paclitaxel 90 mg was infused once a week, and TS-1 100 mg was administered daily. One course consisted of infusion of paclitaxel for 3 weeks followed by 2 weeks rest and administration of TS-1 for 4 weeks followed by 2 weeks rest. At the end of 4 courses of paclitaxel and 3 courses of TS-1, a partial response of the supraclavicular LN metastasis and a complete response of the para-aortic LN metastasis were achieved. There were no remarkable side effects for 2 years after the operation. This chemotherapy might be suitable to treat patients with LN metastases of advanced gastric cancer.

Method for spontaneous constriction and closure of portocaval shunt using a ligamentum teres hepatis in small-for-size graft liver transplantation.

BACKGROUND: We have developed a new portocaval (PC) shunt creation technique for use in small-for-size (SFS) graft liver transplantations. PC shunts are already used to avoid SFS graft syndrome in cases of adult-to-adult living donor liver transplantation (LDLT), but the current method of creating these shunts is subject to two problems: reportal hypertension and liver dysfunction after premature ligation of the PC shunt; and graft atrophy and liver dysfunction because of the loss of portal venous flow late in the recovery period after LDLT. METHODS: Our new technique avoids these two problems simultaneously by using the interposed obliterated ligamentum teres hepatis (LTH) to create the PC shunt, then obstructing the PC shunt after regeneration of the liver graft. RESULTS: We have used this technique in four cases. In all cases, portal venous pressures after shunting were lower than those before shunting, and PC shunts with lower portal pressure were obstructed faster than that with higher portal pressure. CONCLUSION: Our results suggest that the LTH can function as a shape memory graft to reduce portal venous flow after regeneration of the graft liver. Using the LTH to create a PC shunt might help to prevent both SFS graft syndrome early in the recovery period after LDLT and loss of portal venous flow late in the recovery period.

Management of major portosystemic shunting in small-for-size adult living-related donor liver transplantation with a left-sided graft liver.

PURPOSE: We investigated the mechanisms of small-for-size graft syndrome by time-lag ligation, a novel approach to treating major portosystemic shunts in small-for-size adult living-related donor liver transplantation (LRDLT) using left-sided graft liver. METHODS: Five patients with end-stage liver failure and major splenorenal shunting underwent LRDLT using left lobe grafts. The average graft volume to recipient body weight (GV/RBW) ratio was 0.68 +/- 0.14. Two patients underwent time-lag ligation of their splenorenal (SR) shunts on postoperative days (PODs) 8 and 14, respectively. The shunts of the other three patients were untreated. RESULTS: The portal pressures in the first patient who underwent time-lag ligation rose above 300 mmH(2)O and remained there for 2 weeks. Thus, we ligated the SR shunt in the second patient on POD 14, resulting in an increase from 177 mmH(2)O to 258 mmH(2)O, but it decreased again thereafter. In the other three patients, the SR shunt was not ligated because portal blood flow volumes remained sufficient. Total bilirubin levels in the first time-lag ligation patient rose to 16 mg/dl, paralleling the rise in portal pressures. Although they increased after ligation in the second patient, they did not exceed 10 mg/dl. CONCLUSIONS: We recommend time-lag ligation if portal venous blood flow decreases in the early post-transplant period, but not until at least 2 weeks after transplantation. If the portal venous blood flow does not decrease, early postoperative ligation is unnecessary. If there are no major portosystemic shunts, making a portosystemic shunt might decompress excessive portal hypertension. With donor safety priority in LRDLT, novel approaches must be developed to enable the use of smaller donor grafts. We describe a potential means of using left lobe grafts in adult LRDLT.