How transplant surgeons can overcome the inevitable insufficiency of allograft size during adult living-donor liver transplantation: strategy for donor safety with a smaller-size graft and excellent recipient results

Small-for-size grafts are an issue in liver transplantation. Portal venous pressure (PVP) was monitored and intentionally controlled during living-donor liver transplantation (LDLT) in 155 adult recipients. The indocyanine green elimination rate (kICG) was simultaneously measured in 16 recipients and divided by the graft weight (g) to reflect portal venous flow (PVF). The target PVP was <20 mmHg. Patients were divided by the final PVP (mmHg): Group A, PVP < 12; Group B, 12 ≤ PVP < 15; Group C, 15 ≤ PVP < 20; and Group D, PVP ≥ 20. With intentional PVP control, we performed splenectomy and collateral ligation in 80 cases, splenectomy in 39 cases, and splenectomy, collateral ligation, and additional creation in five cases. Thirty-one cases received no modulation. Groups A and B showed good LDLT results, while Groups C and D did not. Final PVP was the most important factor for the LDLT results, and the PVP cutoffs for good outcomes and clinical courses were both 15.5 mmHg. The respective kICG/graft weight cutoffs were 3.5580 × 10(-4) /g and 4.0015 × 10(-4) /g. Intentional PVP modulation at <15 mmHg is a sure surgical strategy for small-for-size grafts, to establish greater donor safety with good LDLT results. The kICG/graft weight value may have potential as a parameter for optimal PVF and a predictor for LDLT results.     

Impact of a Left-Lobe Graft Without Modulation of Portal Flow in Adult-to-Adult Living Donor Liver Transplantation

In adult-to-adult living donor liver transplantation (LDLT), left-lobe grafts can sometimes be small-for-size. Although attempts have been made to prevent graft overperfusion through modulation of portal inflow, the optimal portal venous circulation for a liver graft is still unclear. Hepatic hemodynamics were analyzed with reference to graft function and outcome in 19 consecutive adult-to-adult LDLTs using left-lobe grafts without modulation of graft portal inflow. Overall mean graft volume (GV) was 398 g, which was equivalent to 37.8% of the recipient standard liver volume (SV). The GV/SV ratio was less than 40% in 13 of the 19 recipients. Overall mean recipient portal vein flow (PVF) was much higher than the left PVF in the donors. The mean portal contribution to the graft was markedly increased to 89%. Average daily volume of ascites revealed a significant correlation with portal vein pressure, and not with PVF. When PVP exceeds 25 mmHg after transplantation, modulation of portal inflow might be required in order to improve the early postoperative outcome. Although the study population was small and contained several patients suffering from tumors or metabolic disease, all 19 patients made good progress and the 1-year graft and patient survival rate were 100%. A GV/SV ratio of less than 40% or PVF of more than 260 mL/min/100 g graft weight does not contraindicate transplantation, nor is it necessarily associated with a poor outcome. Left-lobe graft LDLT is still an important treatment option for adult patients.     

Impact of portal venous pressure on regeneration and graft damage after living-donor liver transplantation.

Several reports claim that portal hypertension after living-donor liver transplantation (LDLT) adversely affects graft function, but few have assessed the impact of portal venous pressure (PVP) on graft regeneration. We divided 32 adult LDLT recipients based on mean PVP during the 1st 3 days after LDLT into a group with a PVP > or = 20 mm of Hg (H Group; n = 17), and a group with a PVP < 20 mm of Hg (L Group; n = 15). Outcome in the H Group was poorer than in the L Group (58.8 vs. 92.9% at 1 year). Peak peripheral hepatocyte growth factor (HGF) during the 1st 2 weeks was higher in the H Group (L: 1,730 pg/mL, H: 3,696 pg/mL; P < .01), whereas peak portal vascular endothelial growth factor (VEGF) level during the 1st week was higher in the L Group (L: 433 pg/mL, H: 92 pg/mL; P < .05). Graft volume (GV) / standard liver volume (SLV) was higher in the H Group (L / H, at 2, 3, and 4 weeks, and at 3 months: 1.02 / 1.24, .916 / 1.16, .98 / 1.27, and .94 / 1.29, respectively; P < .05). Peak serum aspartate aminotransferase, bilirubin levels, and international normalized ratio after LDLT were significantly higher in the H Group, as was mean ascitic fluid volume. In conclusion, early postoperative PVP elevation to 20 mm of Hg or more was associated with rapid graft hypertrophy, higher peripheral blood HGF levels, and lower portal VEGF levels; and with a poor outcome, graft dysfunction with hyperbilirubinemia, coagulopathy, and severe ascites. Adequate liver regeneration requires an adequate increase in portal venous pressure and flow reflected by clearance of HGF and elevated VEGF levels.     

Correlation of portal venous velocity and portal venous flow with short-term graft regeneration in recipients of living donor liver transplants

BACKGROUND: To evaluate the correlation of postoperative portal venous velocity (PVV) and portal venous flow (PVF) with the degree of short-term graft regeneration in recipients of living donor liver transplantation (LDLT). MATERIALS AND METHODS: Between August 2005 and April 2006, we performed 44 adult-to-adult LDLTs with right-lobe grafts, of whom 31 recipients were included in this study. Doppler ultrasonography was used to measure PVV (cm/s) and PVF (mL/min) on postoperative days (POD) 1, 3, and 5 or 6. Portal venous velocity index (PVI) was defined as the ratio of PVV to graft weight (GW), and portal flow volume index (PFI) as the ratio of PVF to GW. Graft regeneration rate (GRR), defined as the ratio of the volume of regenerated graft to GW, was estimated by dividing computed tomography volumetry at POD 7 by GW measured after retrieval of the graft. We analyzed the relationship between GRR and PVV, PVF, PVI, and PFI. RESULTS: GW ranged between 528 g and 1040 g (mean = 735 g) and GRR ranged between 118% and 278% (mean = 172%). Although neither PVV nor PVF correlated with GRR, PVI and PFI at POD 1 (P = .009) and PFI at POD 5 or 6 (P = .012) significantly correlated with GRR at POD 7. CONCLUSION: PVI and PFI at POD 1 are useful indicators to predict short-term graft regeneration in recipients of LDLT.     

Peripheral venous pressure as a predictor of central venous pressure during orthotopic liver transplantation

STUDY OBJECTIVE: To assess the reliability of peripheral venous pressure (PVP) as a predictor of central venous pressure (CVP) in the setting of rapidly fluctuating hemodynamics during orthotopic liver transplant surgery. DESIGN: Prospective clinical trial. SETTING: UCLA Medical Center, main operating room-liver transplant surgery. PATIENTS: Nine adult patients with liver failure undergoing orthotopic liver transplant surgery. INTERVENTIONS: A pulmonary artery catheter and a 20-g antecubital peripheral intravenous catheter dedicated to measuring PVP were placed in all patients after standard general endotracheal anesthesia induction and institution of mechanical ventilation. MEASUREMENTS: Peripheral venous pressure and CVP were recorded every 5 minutes and/or during predetermined, well-defined surgical events (skin incision, venovenous bypass initiation, portal vein anastamosis, 5 minute post graft reperfusion, abdominal closure). Pulmonary artery pressure and cardiac output (via thermodilution) were recorded every 15 and 30 minutes, respectively. MAIN RESULTS: Peripheral venous pressure (mean +/- SD) was 11.0 +/- 4.5 mmHg vs a CVP of 9.5 +/- 5.0; the two measurements differed by an average of 1.5 +/- 1.6 mmHg. Peripheral venous pressure correlated highly with CVP in every patient, and the overall correlation among all nine patients calculated using a random-effects regression model was r = 0.95 (P < 0.0001). A Bland-Altman analysis used to determine the accuracy of PVP in comparison to CVP yielded a bias of -1.5 mmHg and a precision of +/-3.1 mm Hg. CONCLUSION: Our study confirms that PVP correlates with CVP even under adverse hemodynamic conditions in patients undergoing liver transplantation.     

Transumbilical portal venous catheterization: a useful adjunct in left lobe living donor liver transplantation

To improve the processes used for perfusion of the explanted graft and measuring the portal venous pressure (PVP) in adult living donor transplantation (LDLT), we performed transumbilical portal venous catheterization (TPVC) to reopen the umbilical vein and insert the catheter for seven adult patients undergoing left lobe LDLT. There were no major complications as a result of this procedure. This procedure prior to implanting the graft was derived from our experience and is a classic diagnostic technique used during liver surgery. It is a simple and effective procedure for perfusion and washout of the graft and for the safe monitoring of the intraoperative PVP. We hope that this technique for left lobe LDLT will be helpful to others using postoperative PVP monitoring, administration of therapeutic drugs through the portal vein, and temporal portal decompression by preparation of extracorporeal shunting in patients with a small‐for‐size graft.     

Effects of exogenous endothelin-1 application on liver perfusion in native and transplanted porcine livers

PURPOSE: This study was designed to assess and differentiate the impact of progressivly increasing portal venous endothelin-1 (ET) plasma concentrations on hepatic micro- and macroperfusion of native porcine livers (Group A) and liver grafts after experimental transplantation (Group B). METHODS: A standardized gradual increment in systemic ET plasma concentration (0-58 pg/ml) was induced by continuous ET-1 infusion into the portal vein in both groups (A: n = 10, B: n = 10). Control animals received only saline (n = 5, each group). Hepatic microcirculation (HMC) was quantified by thermodiffusion electrodes, hepatic artery flow (HAF), and portal venous flow (PVF) by Doppler flowmetry. RESULTS: No changes in ET or perfusion parameters were observed in controls. The mean ET level after orthotopic liver transplantation (OLT) in Group B was elevated (baseline: 3.8 +/- 2.4 pg/ml) compared with Group A (2.8 +/- 1.9 pg/ml). With rising ET levels HAF decreased progressively in Group A from 205 +/- 97 (baseline) to 160 +/- 72 ml/min, and in Group B from 161 +/- 87 to 146 +/- 68 ml/min. PVF decreased in Group A from 722 +/- 253 to 370 +/- 198 ml/min, and in Group B from 846 +/- 263 to 417 +/- 203 ml/min. Baseline HMC in Group A was 86 +/- 15 and decreased significantly to 29 +/- 9 ml/100 g/min, and baseline MC in Group B was 90 +/- 22 and decreased to 44 +/- 32 ml/100 g/min. No significant alteration in systemic circulation was noted at the ET concentrations investigated. CONCLUSIONS: Significant impairment of hepatic micro- and macrocirculation was detected after induction of systemic ET levels above 9.4 pg/ml both in native and in transplanted livers. Disturbance of HMC was caused predominantly by reduction of portal venous flow, while the effect of ET on HAF was less pronounced. Characteristics of flow impairment in transplanted and native livers were analogous after short cold ischemic graft storage (6 h).     

Left lobe adult-to-adult living donor liver transplantation: Should portal inflow modulation be added?

Recently, the successful application of portal inflow modulation has led to renewed interest in the use of left lobe grafts in adult-to-adult living donor liver transplantation (LDLT). However, data on the hepatic hemodynamics supporting portal inflow modulation are limited, and the optimal portal circulation for a liver graft is still unclear. We analyzed 42 consecutive adult-to-adult left lobe LDLT cases without splenectomy or a portocaval shunt. The mean actual graft volume (GV)/recipient standard liver volume (SLV) ratio was 39.8% ± 5.7% (median = 38.9%, range = 26.1%-54.0%). The actual GV/SLV ratio was less than 40% in 24 of the 42 cases, and the actual graft-to-recipient weight ratio was less than 0.8% in 17 of the 42 recipients. The mean portal vein pressure (PVP) was 23.9 ± 7.6 mm Hg (median = 23.5 mm Hg, range = 9-38 mm Hg) before transplantation and 21.5 ± 3.6 mm Hg (median = 22 mm Hg, range = 14-27 mm Hg) after graft implantation. The mean portal pressure gradient (PVP - central venous pressure) was 14.5 ± 6.8 mm Hg (median = 13.5 mm Hg, range = 3-26 mm Hg) before transplantation and 12.4 ± 4.4 mm Hg (median = 13 mm Hg, range = 1-21 mm Hg) after graft implantation. The mean posttransplant portal vein flow was 301 ± 167 mL/minute/100 g of liver in the 38 recipients for whom it was measured. None of the recipients developed small-for-size syndrome, and all were discharged from the hospital despite portal hyperperfusion. The overall 1-, 3-, and 5-year patient and graft survival rates were 100%, 97%, and 91%, respectively. In conclusion, LDLT with a left liver graft without splenectomy or a portocaval shunt yields good long-term results for adult patients with a minimal donor burden.     

Normal hepatic hemodynamics during early postoperative period in recipients with adult live donor liver transplantation

To recognize "normal" hepatic hemodynamics after live donor liver transplantation (LDLT), we analyzed Doppler parameters on recipients with a right liver graft and donors after extended left hepatectomy. Theoretically these values should be the same. From April 2000 to October 2004, 20 LDLTs were performed using a right liver graft. The 10 recipients without postoperative complications and their donors were included in this study. Portal venous velocity (PVV; cm/s), hepatic arterial peak systolic velocity (cm/s), and hepatic venous peak velocity (HVPV; cm/s) were measured during the first 2 weeks. In donors PVV and HVPV after LDLT were significantly higher after than before left hepatectomy: 19.2 +/- 4.2 vs. 31.5 +/- 13.0 cm/s (P = .013) and 23.0 +/- 7.2 vs. 41.8 +/- 10.3 cm/s respectively (P = .010). However, there were mild degrees of increased PVV and HVPV. In recipients, a markedly increased PVV (106.3 +/- 45.2 cm/s on day 1) was significantly higher than that in donors on each postoperative day. The hepatic arterial resistive index in recipients was also significantly higher than that in donors on each postoperative day, for example, 0.72 +/- 0.11 vs 0.62 +/- 0.04 on day 1 (P = .0326). In conclusion, we have shown "abnormal" hepatic hemodynamics in even those recipients without complications during the early postoperative period after LDLT.     

Explanted portal vein grafts for middle hepatic vein tributaries in living-donor liver transplantation

BACKGROUND: The availability of a venous graft is limited in the setting of living donor liver transplantation (LDLT), and the management of the middle hepatic vein middle hepatic vein tributaries in right lobe LDLT still remains controversial. METHODS: Twenty-three right lobe LDLT grafts, with the reconstruction of middle hepatic vein tributaries using the explanted portal veins from the explanted livers, were evaluated for the patency, postLDLT liver function tests, and graft survival. RESULTS: The methods of outflow reconstruction were classified into three types: the interposition of the graft to the middle/left hepatic vein (n=12), to the vena cava (n=9), and to the vena cava as a co-orifice with the graft right hepatic vein (n=2). The 1- and 3-year patency rates were 76.7% and 76.7% respectively, with the graft occlusion in five cases. The occluded cases (n=5) had significantly higher aspartate aminotransferase and alanine transaminase levels as compared with those of patent cases (n=18) at 4 weeks after transplantation (P<0.01). However, there was no significant difference in the total bilirubin and prothrombin time in either group during the observation periods. The 1- and 3-year graft survival rates were 91.1% and 91.1%, respectively. In addition, there was no graft loss due to occlusion. CONCLUSION: The use of the recipient's explanted full-length hilar portal vein for the reconstruction of the middle hepatic vein tributaries is thus considered to be a feasible and valuable strategy in the setting of a right lobe LDLT, where appropriate vascular grafts are not always available.     

Surgical procedures for decompression of excessive shear stress in small-for-size living donor liver transplantation--new hepatic vein reconstruction

We have reported that acute elevation of portal pressure, reflecting wall shear stress of sinusoidal endothelial cells, triggers liver regeneration after partial hepatectomy and that excessive portal hypertension induces liver failure. For prevention of excessive shear stress in small-for-size living donor liver transplantation (LDLT), we developed a new hepatic vein reconstruction to expand the anastomotic site. Fourteen adult patients, who underwent LDLT, were divided into two groups: previous end-to-end hepatic vein reconstruction in nine patients (group P) and the new method in five patients (group N). The outside middle and left hepatic veins of the graft were incised and enlarged to 40 mm. The vena cava was cut 40 mm longitudinally. The graft was positioned a quarter turn counterclockwise with the hepatic vein of the graft anastomosed end-to-side to the vena cava longitudinally. Postoperative portal pressures and serum total bilirubin levels of these two groups showed portal pressure in group N to rapidly decrease below 25 cm H2O following LDLT. No cases showed posttransplanted hyperbilirubinemia above 10 mg/dL in group N; however, all cases were small-for-size grafts. Moreover, serum total bilirubin levels in group N were significantly lower than those in group P. This procedure is simple despite not using a venous patch. If the hepatic vein is narrow or obstructed, such as in Budd-Chiari syndrome, the procedure is applicable. Even in small-for-size grafts, excessive tension did not occurred at the portal vein or hepatic artery anastomoses. Moreover, it is possible to avoid outflow block and posttransplanted hyperbilirubinemia.     

Portacaval shunt and inferior vena cava preservation in orthotopic liver transplantation

The aim was to study the advantages of the use of a temporary portacaval shunt (PCS) with inferior vena cava (IVC) preservation during the piggyback technique for the anhepatic phase of orthotopic liver transplantation (OLT) performed in cirrhotic patients. Two groups of cirrhotic patients who underwent OLT with piggyback technique were compared; one with a PCS (n = 57) and the other, without PCS (n = 54). Patients with fulminant hepatitis, retransplantation, portal thrombosis, and previous portosystemic shunts were excluded. In both groups graft reperfusion was achieved by simultaneous arterial and venous revascularization. Donor, recipient, and surgical characteristics were similar in both groups. The PCS group had a significantly higher portal venous flow (PVF) than the no-PCS group (773 +/- 402 mL/min vs 555 +/- 379 mL/min, P = .004). Therefore, two subgroups were studied; the high PVF subgroup A (>800 mL/min), mean 1099 +/- 261 mL/min, and the low PVF subgroup B (<800 mL/min), mean 433 +/- 423 mL/min. Subgroup A, who were treated with PCS, required fewer blood transfusions and displayed better postoperative renal function; whereas, no differences were observed among subgroup B patients with versus without PCS. In conclusion, the use of a temporary PCS with piggyback technique during OLT in cirrhotics has advantages in patients who still maintain a high portal venous flow.     

Changes in portal venous pressure in the early phase after living donor liver transplantation: pathogenesis and clinical implications

BACKGROUND: Although living-donor liver transplantation (LDLT) has been accepted for adult populations, the occurrence and pathogenesis of small-for-size syndrome remain highly controversial. METHODS: Portal venous pressure (PVP) was measured in 79 cases of LDLT from anhepatic phase to day 14. PVP was monitored through a catheter inserted via the inferior mesenteric vein. In a separate series of seven cases of adult LDLT, the splenic artery was ligated following arterial reperfusion. RESULTS: For days 2 to 4 and 9 to 11, recipients of small-for-size graft (<0.8% of body weight) displayed significantly higher PVP than recipients of larger grafts. The 13 patients with elevated mean PVP (>or=20 mm Hg) early in the first week (days 0-4) demonstrated significantly worse survival (84.5% vs. 38.5% at 6 months; P < 0.01), but this was not applicable to elevated mean PVP late in the first week (days 5-7). Elevated PVP early in the first week was also associated with higher incidence of bacteremia, cholestasis, prolonged prothrombin time, and ascites. Splenic artery ligation (SAL) immediately reduced PVP from 10 to 20 mm Hg (median, 16 mm Hg) to 9 to 13 mm Hg (median, 11 mm Hg; P = 0.02). Posttransplant PVP was significantly lower in SAL patients than in non-SAL patients from days 2 to 7 despite small graft size. Early PVP in SAL patients was consistently below 20 mm Hg, and survival was significantly better than in non-SAL patients with high early PVP (P < 0.01). CONCLUSION: Elevated PVP in the early phase is strongly associated with poor patient survival attributable, at least in part, to small-for-size graft. Further elucidation of the pathogenesis behind this phenomenon and efforts to modify PVP will be key to improving results.     

Living donor liver transplantation and management of portal venous pressure

Small-for-size syndrome occurs in the presence of a reduced mass of liver that is insufficient to maintain normal liver function. It has been speculated that this dysfunction is principally associated with graft exposure to excessive portal perfusion. The aim of these cases was to evaluate the efficacy of octreotide, a splanchnic vasoconstrictor, and esmolol, a selective beta-blocker, to modify the portal perfusion in the postoperative phase after left living related liver transplantation (LRLT). Four patients who underwent left LRLT with graft-to-recipient weight ratios of 0.60 +/- 0.24 were studied with a catheter placed in a jejunal vein. We observed high basal values of hepatic venous pressure gradient (HVPG) and portal vein flow (PVF). Octreotide infusion decreased HVPG, an effect that was more pronounced when it was combined with esmolol. The administration of both drugs was also associated with an improvement in portal vein oxygen saturation. Despite variation in PVF, the plasma disappearance rate of indocyanin green did not change during the infusion of the two drugs. In conclusion, octreotide and esmolol infusion allowed a manipulation of portal vein pressure that should be measured in left LRLT using a small-for-size graft.     

Arterialization of the portal blood with a new model of flow diversion: an experimental study

Arterialization of the portal blood with double shunts, cavo-mesenteric venous and femoro-femoral arterio-venous, was attempted in dogs. The experimental model was studied in three groups. Group-I was concerned with the condition immediately after establishment of the model. Group-II-A was referred to the study on the established model with hepatic artery ligation for seven days. Group-II-B was evaluated under hepatic artery ligation and absent participation in arterialization and shunts. The ratio of portal venous flow (PVF) to cardiac output (CO) in group-I revealed significant increase from 23 +/- 6% to 56 +/- 9% (p less than 0.01). Portal venous PO2 (PVO2) also increased from 48 +/- 7 mmHg to 65 +/- 9 mmHg (p less than 0.01). Portal venous pressure, however, remained below 200 mmH2O. Persistent increase of CO (150% of the control) and PVF/CO were seen in observation of group-II-A. Histopathological appearance of the liver was normal in group-II-A. Group-II-B revealed a high mortality rate (8/9) with necrosis of the liver by seventh postoperative day. The experimental model provides the useful flow diversion with arterialized blood to the portal flow. The arterialization of the portal flow may play an important role in the recovery of the ischemic liver cell in the preservation of the liver graft and in hepatic regeneration after extended resection.     

Correlation of peripheral venous pressure and central venous pressure in surgical patients

OBJECTIVE: To determine the degree of agreement between central venous pressure (CVP) and peripheral venous pressure (PVP) in surgical patients. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Patients without cardiac dysfunction undergoing major elective noncardiac surgery (n = 150). MEASUREMENTS AND MAIN RESULTS: Simultaneous CVP and PVP measurements were obtained at random points in mechanically ventilated patients during surgery (n = 100) and in spontaneously ventilating patients in the postanesthesia care unit (n = 50). In a subset of 10 intraoperative patients, measurements were made before and after a 2-L fluid challenge. During surgery, PVP correlated highly to CVP (r = 0.86), and the bias (mean difference between CVP and PVP) was -1.6 +/- 1.7 mmHg (mean +/- SD). In the postanesthesia care unit, PVP also correlated highly to CVP (r = 0.88), and the bias was -2.2 +/- 1.9 (mean +/- SD). When adjusted by the average bias of -2, PVP predicted the observed CVP to within +/-3 mmHg in both populations of patients with 95% probability. In patients receiving a fluid challenge, PVP and CVP increased similarly from 6 +/- 2 to 11 +/- 2 mmHg and 4 +/- 2 to 9 +/- 2 mmHg. CONCLUSION: Under the conditions of this study, PVP showed a consistent and high degree of agreement with CVP in the perioperative period in patients without significant cardiac dysfunction. PVP -2 was useful in predicting CVP over common clinical ranges of CVP. PVP is a rapid noninvasive tool to estimate volume status in surgical patients.     

Rehospitalization after pediatric living-donor liver transplantation

BACKGROUND: Although rehospitalization is one of the factors affecting quality of life after successful liver transplantation, the effects of rehospitalization have not been assessed to date. PATIENTS AND METHODS: Of 40 consecutive cases of pediatric living-donor liver transplantation (LDLT) performed between April 1994 and October 2000, 28 patients with a graft survival of more than 1 year were enrolled in this study to examine rehospitalization after successful LDLT. The rate and cause of rehospitalization were analyzed retrospectively on the basis of medical records. RESULTS: A total of 23 of the 28 patients were rehospitalized. There were 84 episodes of rehospitalization. The mean number of rehospitalization days per episode per patient was 21.06 +/- 21.02 days. The rate of total rehospitalization days to the days after the hospitalization for LDLT was 6.56% +/- 8.73%. Rehospitalization episodes were attributable to the following: cholangitis (21.4%), viral infection (16.7%), and portal stenosis (PS) (13.1%). Rehospitalization as the result of rejection accounted for 9.5% of the episodes. The period of rehospitalization was long in the case of cholangitis (49.7 +/- 62.4 days), PS (13.8 +/- 13.4 days), and rejection (52.9 +/- 45.4 days). Although there were a lot of rehospitalization episodes as the result of viral infection subsequent to cholangitis, each rehospitalization period lasted 4.4 +/- 6.6 days. CONCLUSION: It is suggested that prevention of cholangitis and PS, which were the causes of frequent and long rehospitalization periods, would result in a reduction of rehospitalization and therefore a better quality of life after pediatric LDLT.     

Improvement of morphological changes after 70% hepatectomy with portocaval shunt: preclinical study in porcine model

BACKGROUND: After extensive hepatectomy, excessive portal venous flow (PVF) and elevated portal venous pressure (PVP) may lead to postoperative liver damage. We have evaluated the use of portocaval shunt (PCS) to control PVF and PVP following partial hepatectomy (PH) to reduce the postoperative liver damage. METHOD: Twenty-four pigs were divided into two Groups: Group C (n = 10) underwent 70% PH alone and Group S (n = 14) underwent 70% PH with PCS. The changes in PVF, PVP, serum liver function tests, and histology were evaluated. RESULTS: PVP and PVF per unit of remnant liver weight and serum total bilirubin levels in Group S were significantly lower than those in Group C postoperatively (P < 0.05). Histology showed that there were significant differences in hepatocyte ballooning, necrosis, and neutrophil aggregation between the two groups (P < 0.05). In particular, hepatic necrosis was observed in zone 3 of Group C as centrilobular necrosis. These results suggest that hepatic and sinusoidal damage after 70% PH were more severe in Group C than in Group S, with the latter group maintaining an almost normal ultrastructural appearance. Hepatocyte apoptotic index differed significantly between the two groups (P < 0.0001). CONCLUSION: After 70% PH, extensive centrolobular necrosis and neutrophil aggregation were present and may have caused liver damage, manifested as hyperbilirubinemia and coagulopathy. The delayed liver regeneration with PCS may reduce the postoperative liver damages rather than the rapid liver hypertrophy. The diversion of PVF with PCS to maintain adequate PVP is a very effective procedure for avoiding the postoperative liver failure after extensive hepatectomy.     

Analysis of systemic and regional procalcitonin serum levels during liver transplantation

Elevated procalcitonin (PCT) levels are observed early after orthotopic liver transplantation (OLTx). The aim of this study was to evaluate the changes in systemic and regional PCT serum levels from the time of organ harvesting until the early postoperative phase of OLTx ( n=28) and to investigate the prognostic suitability of postoperative changes in PCT level for the outcome of OLTx ( n=61). Only in seven of 28 donors were higher PCT levels found (0.84+/-0.43 ng/ml). During organ preservation, hepatectomy, and in the anhepatic phase, the PCT levels were in the normal range; in 11 of 28 cases hepatic vein PCT levels were higher during graft flush with own blood than the systemic or portal vein samples at the same time (1.27+/-0.43 ng/ml vs 0.16+/-0.26 ng/ml and 0.23+/-0.15 ng/ml, respectively, P<0.02). The elevation of PCT levels began immediately after graft reperfusion (1.04+/-0.77 ng/ml vs 0.27+/-0.22 ng/ml, P<0.001), and the levels at postoperative day 2 were significantly higher in the case of postoperative complications (30.6+/-19.6 ng/ml vs 4.8+/-3.6 ng/ml, P<0.001).     

Feasible usage of ABO incompatible grafts in living donor liver transplantation

Background

The use of ABO incompatible (ABOi) graft in living donor liver transplantation (LDLT) has not been an established procedure worldwide.

Methods

Four hundred and eight adult LDLTs, using ABOi (n=19) and non-ABOi (n=389) grafts, were performed as a single center experience.

Results

In ABOi-LDLT group (n=19), median isoagglutinin titer before plasma exchange (PE) at LDLT and after LDLT (max) was ×256, ×32 and ×32, respectively. Rituximab was given at 21.8±6.1 days before LDLT and PE was performed 3.7±1.6 times. Although ABOi-LDLTs had increased rate of splenectomy (89.4% vs. 44.7%, P<0.001) and lower portal venous pressure (PVP) at the end of surgery (13.8±1.1 vs. 16.9±0.2 mmHg, P=0.003), other operative factors including graft ischemic time, operative time and blood loss were not different between the groups. Although ABOi-LDLTs had increased incidence of cytomegalovirus infection (52.6% vs. 22.9%, P=0.007), other post-transplant complications including bacterial sepsis and acute rejection were not different between the groups. The 5-year graft survival rate was 87.9% in ABOi-LDLTs and 80.3% in non-ABOi-LDLTs (P=0.373).

Conclusions

ABOi-LDLT could be safely performed, especially under rituximab-based protocol.