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.     

Minimally Invasive 360° Fusion Using a Combination of INFIX and Minimally Invasive Spinopelvic Fixation by Intraoperative Computed Tomography Navigation for Unstable Pelvic Ring Fracture: A Technical Note

Objective

Fluoroscopy is often used in the surgery of unstable pelvic ring fractures, and improved safety in implant placement is an issue. An anterior subcutaneous pelvic fixator (INFIX) combined with a percutaneous screw has been reported to be a minimally invasive and effective surgical technique for unstable pelvic ring injuries. However, although percutaneous screw fixation is minimally invasive, its indications for fracture fixation and fractures with large fragment displacements in the vertical plane remain controversial. Therefore, this technical note aims to describe a new technique for unstable pelvic ring fractures.

Methods

We describe a 360° fusion of the pelvic ring to treat unstable pelvic ring fractures, including vertical shear pelvic ring fractures, using an intraoperative CT navigation system. Seven patients were treated with 360° fusion for type C pelvic ring fractures. In surgery, after reducing the fracture with external fixation, intraoperative CT navigation is used to perform a 360° fusion with INFIX and minimally invasive surgical spinopelvic fixation (MIS-SPF). We will introduce a typical case and explain the procedure.

Results

A 360° fixation was performed, and no perioperative complications were noted. The mean blood loss was 253.2 ± 141.0 mL, and the mean operative time was 224.3 ± 67.4 min. In a typical case, bone union was obtained 1 year after surgery, and we removed all implants.

Conclusions

MIS-SPF has a strong fixation force and helps reduce fractures' horizontal and vertical planes. In addition, 360° fusion with intraoperative CT navigation may help treat unstable pelvic ring fractures.     

Microcirculation of kidney and skin during left ventricular assisted circulation--comparative studies of pulsatile and nonpulsatile assists]

We examined microcirculation of the kidney and skin over a six-hour period in an acute myocardial infarction model in pigs. The outflow cannula was placed in the ascending aorta, the inflow cannula was placed the in left atrium, and a pump was connected to each (pulsatile group, Zeon Medical pneumatic pump; nonpulsatile group, Nikkiso HPM-15). Items examined included the regional blood flow of the cortex and medulla in the kidney and skin, renal and carotid arterial flow, arterial ketone body ratio (AKBR), lactate/pyruvic acid (L/P), BUN, creatinine, and beta 2-microglobulin. After the experimental study, the major organs were removed and a pathological study was performed. The mean aortic pressure after the assist could be maintained at about 100 mmHg. There were no significant differences between the two groups in mean aortic pressure and total cardiac output. Under assisted circulation, the pulse pressure was maintained at about 15 mmHg in the nonpulsatile group and about 40 mmHg in the pulsatile group. After the assist, there were no significant differences in the carotid arterial blood flow between the two groups. However, there were significant differences between the two groups in the renal arterial, renal cortical, and regional skin blood flows. In the laboratory data, there were significant differences between the two groups in AKBR, L/P, and beta 2-microglobulin. Pathological findings on the kidney in the nonpulsatile group showed expansion of the proximal tubes, retention of red blood cells, and expansion of blood capillaries within the glomerulus. On the other hand, the pulsatile group showed almost normal formation. In the lungs, the nonpulsatile group showed edematous change in the air cells and the pulsatile group showed almost normal formation. The results of the previous and current study indicated that the pulsatile assist produced superior circulation in the kidney and peripheral organs and superior cellular metabolism in the early treatment of acute left cardiac failure. On the other hand, nonpulsatile assisted circulation was found to be ineffective in maintaining the circulation in the body, and to be potentially capable of causing irreversible damage of major organs if continuous for more than three hours. The results also indicated that pulsatility was necessary to maintain normal circulation in the peripheral organs and cellular metabolism in the early treatment of acute left cardiac failure.     

A case of Stanford type A acute aortic dissection associated wih a distal aoric arch atherosclerotic aneurysm

We report a rare case of Stanford type A acute aortic dissection associated with a distal aortic arch atherosclerotic aneurysm. A 71-year-old female was referred to us with the diagnosis of thrombosed Stanford type A acute aortic dissection, however on the nextday transesophageal echocardiography revealed the false lumen has been recanalized. In the operation, there was a distal aortic arch atherosclerotic aneurysm which was unidetified at the preoperation. It is very rare that the dissection originated from atherosclerotic aneurysm and proceeded to proximal and distal portion of the aorta.     

Intraoperative direct measurement of hepatic arterial buffer response in patients with or without cirrhosis.

The hepatic arterial buffer response (HABR) is an intrinsic regulatory mechanism of the hepatic artery (HA) that compensates for reductions in portal venous (PV) blood flow. Whether this response is maintained in patients with cirrhosis (LC) is unclear. The aim of the present study was to examine whether HABR is maintained in patients with LC using direct blood flow measurements. PV and HA blood flow were intraoperatively measured and compared in patients with (LC group, n = 39) or without (control group, n = 22) cirrhosis at baseline (baseline HABR) and after PV clamping (acute HABR) using an ultrasound transit-time flowmeter. In contrast to the proportional relationship between the baseline PV and HA blood flow observed in the control group, HA blood flow and the HA-PV flow ratio increased when PV blood flow decreased in the LC group, suggesting that the baseline HABR had already been activated. Acute HABR, evaluated by the absolute and relative changes in HA blood flow and by the buffer capacity, was blunted in the LC group (P < 0.001, P < 0.01, and P = 0.01, respectively). An association between the degree of acute HABR impairment and the level of baseline HABR activation (HA-PV flow ratio) could not be confirmed in the LC group. In conclusion, the baseline HABR appears to be continuously activated in patients with LC; this phenomenon probably results in the impairment of the acute HABR.     

Risk Factors for Early Recurrence of Single Lesion Hepatocellular Carcinoma After Curative Resection

Background and objectives

Hepatic resection is established as the treatment for HCC. However, patients sometimes experience early recurrence of HCC (ER HCC) after curative resection.

Methods

A retrospective analysis was conducted for 193 patients with single HCC who underwent curative liver resection in our medical center between April 2000 and March 2013. We divided the cohort into two groups; early recurrence group (ER G) which experienced recurrence within 6 months after resection, and non-early recurrence group (NER G). Risk factors for ER HCC were analyzed.

Results

Thirty-nine out of 193 (20.2 %) patients had ER HCC. Univariate analysis showed Glasgow prognostic score (GPS, p = 0.036), neutrophil to lymphocyte ratio (NLR, p = 0.001), level of PIVKA-II (p = 0.0001), level of AFP (p = 0.0001), amounts of blood loss (p = 0.001), operating time (p = 0.002), tumor size (p = 0.0001), stage III and IV (p = 0.0001), and microvascular invasions (portal vein: p = 0.0001 and hepatic vein: p = 0.001) to be associated with ER HCC. By multivariate analysis, there were significant differences in high NLR (p = 0.029) and high AFP (p = 0.0001) in patients with ER HCC.

Conclusions

Preoperative high AFP (more than 250 ng/ml) and high NLR (more than 1.829) were independent risk factors for ER HCC.

     

A case of ruptured true posterior communicating artery aneurysm with neurogenic pulmonary edema treated early by GDC embolization

A case of ruptured true posterior communicating artery aneurysm with neurogenic pulmonary edema is presented. A 31-year-old male suffered the sudden onset of unconsciousness with respiratory dysfunction and pinkish foamy sputum. Computed tomography demonstrated diffuse subarachnoid hemorrhage and chest roentgenogram disclosed pulmonary edema. An emergency cerebral angiogram under controlled ventilation revealed that an aneurysm had arisen from the right posterior communicating artery itself. Subsequently GDC embolization and lumbar drainage were performed on day 0. The patient showed full recovery from pulmonary edema on day 6. He suffered multiple cerebral infarctions caused by vasospasm but he atlained a full recovery after 7 months. The follow-up angiogram showed complete obliteration of the aneurysm. This case report suggests that endovascular treatment with lumbar drainage is useful for severe aneurysmal SAH complicated with pulmonary edema in the acute stage.     

Successful treatment for lung cancer associated with pulmonary sequestration

We encountered a 69-year-old man with lung adenocarcinoma and pulmonary sequestration. The cancer lesion was located in the left upper lobe, with sequestration of the left lower lobe. Left upper lobectomy was performed after induction chemoradiotherapy, but the sequestered lung lobe was preserved because the preoperative respiratory function was poor. Preservation of the sequestered lung during surgery for lung cancer should be considered in patients who have poor respiratory function and no signs of respiratory infection.     

Dimeric but not monomeric soluble CD40 prolongs allograft survival and generates regulatory T cells that inhibit CTL function

BACKGROUND: We previously reported that adenovirus mediated CD40Ig gene therapy (AdCD40Ig) induced long-term acceptance of fully allogeneic rat cardiac allografts, however, the underlying mechanism has not been fully clarified. To address this we have compared the ability of dimeric and monomeric soluble CD40 to prolong allograft survival in vivo and generate regulatory T cells in vitro. METHODS: The ability of CD40Ig (soluble dimmer, containing an Fc region) or CD40/Myc/His (soluble monomer, lacking an Fc region) therapy to generate CD4CD25 regulatory T cells in vitro and to prevent rejection of rat cardiac allografts (ACI to LEWIS) was compared. Immunoregulatory capacity of regulatory T cells generated was determined by suppression of alloantigen specific proliferation and cytotoxicity. RESULTS: Dimeric soluble CD40Ig did not inhibit CD4 T cell proliferation but rather promoted IL-2 production and the generation of CD4CD25 T cells, which regulated alloantigen-specific cytotoxic T lymphocyte activity. Treatment with either AdCD40Ig or purified soluble CD40Ig prolonged the survival of rat cardiac allografts. In contrast, although monomeric soluble CD40/Myc/His suppressed IL-12 production in a similar manner to that achieved by CD40Ig, it did not augment IL-2 production. Moreover, while CD40/Myc/His also generated CD4CD25 T cells, they did not exhibit regulatory activity and administration of soluble CD40/Myc/His failed to prolong cardiac allograft survival. CONCLUSIONS: These results suggest signaling through CD154 in addition to blocking of CD154-CD40 interaction is important for the immunomodulatory effects of soluble CD40Ig. Taken together, our results provide new insight into the mechanism of immunomodulation by soluble CD40 constructs.     

Cytomegalovirus infection following renal transplantation in patients administered low-dose rituximab induction therapy

Anti-CD20 antibody (rituximab) is recently being used as a B cell-depleting agent in renal transplantation (RTx). However, the incidence of infectious complications associated with rituximab therapy remains uncertain. We evaluated the incidence of cytomegalovirus (CMV) infection associated with rituximab therapy in RTx. A total of 83 patients were enrolled. The immunosuppressive regimen consisted of tacrolimus or cyclosporin, mycophenolate mofetil, methylprednisolone and basiliximab. In 54 patients, only one dose of rituximab (200 or 500 mg/kg body weight) was given before RTx. A total of 25 of 43 (58.1%) recipients who were CMV seropositive prior to RTx and who received rituximab induction therapy developed CMV infection, compared to 18 of 24 (75%) CMV seropositive recipients who did not receive rituximab therapy ( P  = 0.1676). A total of 8 of 11 patients who were CMV seronegative prior to RTx and who received rituximab developed CMV infection. However, CMV seroconversion was seen in all 8 of these infected patients. Low-dose rituximab induction therapy in renal transplant recipients appears to have no influence on the incidence of CMV infection and CMV seroconversion. However, we have to consider anti-CMV prophylaxis therapy, because of high incidents of CMV infection, especially for CMV seronegative recipients who received rituximab.