Successful duct-to-duct biliary reconstruction after right hemihepatectomy. Operative planning using virtual 3D reconstructed images

Accurate knowledge of partial anatomy is essential in hepatic surgery but is difficult to acquire. We describe the potential impact of a new technique for constructing three-dimensional virtual images of the portal vein, hepatic artery, and bile ducts and present a representative case. An 80-year-old man was suspected of having papillary cholangiocarcinoma arising in S8 of the liver and extending to the hepatic hilum intraluminaly. Right hemihepatectomy with bile duct resection was planned. However, it was uncertain whether duct-to-duct biliary reconstruction would be possible based on the appearance of the confluence of the right and left hepatic ducts on cholangiogram and conventional computed tomograph. Virtual three-dimensional images of the liver were constructed and revealed vascular and biliary anatomy. They showed that the upper margin of bile duct excision would be 19 mm from the umbilical point of the left portal vein, and that the site of the left branch of the caudate lobe bile duct could be preserved. Based on this information, we performed a sphincter-preserving biliary operation safely without complications. Planning complex biliary surgery may be improved by the use of virtual three-dimensional images of the liver. This approach is especially useful in candidates for postoperative regional chemotherapy.

Basic helix-loop-helix transcription factor heterocomplex of Yas1p and Yas2p regulates cytochrome P450 expression in response to alkanes in the yeast Yarrowia lipolytica

The expression of the ALK1 gene, which encodes cytochrome P450, catalyzing the first step of alkane oxidation in the alkane-assimilating yeast Yarrowia lipolytica, is highly regulated and can be induced by alkanes. Previously, we identified a cis-acting element (alkane-responsive element 1 [ARE1]) in the ALK1 promoter. We showed that a basic helix-loop-helix (bHLH) protein, Yas1p, binds to ARE1 in vivo and mediates alkane-dependent transcription induction. Yas1p, however, does not bind to ARE1 by itself in vitro, suggesting that Yas1p requires another bHLH protein partner for its DNA binding, as many bHLH transcription factors function by forming heterodimers. To identify such a binding partner of Yas1p, here we screened open reading frames encoding proteins with the bHLH motif from the Y. lipolytica genome database and identified the YAS2 gene. The deletion of the YAS2 gene abolished the alkane-responsive induction of ALK1 transcription and the growth of the yeast on alkanes. We revealed that Yas2p has transactivation activity. Furthermore, Yas1p and Yas2p formed a protein complex that was required for the binding of these proteins to ARE1. These findings allow us to postulate a model in which bHLH transcription factors Yas1p and Yas2p form a heterocomplex and mediate the transcription induction in response to alkanes.

Management of massive arterial hemorrhage after pancreatobiliary surgery: does embolotherapy contribute to successful outcome?

Massive arterial hemorrhage is, although unusual, a life-threatening complication of major pancreatobiliary surgery. Records of 351 patients who underwent major surgery for malignant pancreatobiliary disease were reviewed in this series. Thirteen patients (3.7%) experienced massive hemorrhage after surgery. Complete hemostasis by transcatheter arterial embolization (TAE) or re-laparotomy was achieved in five patients and one patient, respectively. However, 7 of 13 cases ended in fatality, which is a 54% mortality rate. Among six survivors, one underwent selective TAE for a pseudoaneurysm of the right hepatic artery (RHA). Three patients underwent TAE proximal to the proper hepatic artery (PHA): hepatic inflow was maintained by successful TAE of the gastroduodenal artery in two and via a well-developed subphrenic artery in one. One patient had TAE of the celiac axis for a pseudoaneurysm of the splenic artery (SPA), and hepatic inflow was maintained by the arcades around the pancreatic head. One patient who experienced a pseudoaneurysm of the RHA after left hemihepatectomy successfully underwent re-laparotomy, ligation of RHA, and creation of an ileocolic arterioportal shunt. In contrast, four of seven patients with fatal outcomes experienced hepatic infarction following TAE proximal to the PHA or injury of the common hepatic artery during angiography. One patient who underwent a major hepatectomy for hilar bile duct cancer had a recurrent hemorrhage after TAE of the gastroduodenal artery and experienced hepatic failure. In the two patients with a pseudoaneurysm of the SPA or the superior mesenteric artery, an emergency re-laparotomy was required to obtain hemostasis because of worsening clinical status. Selective TAE distal to PHA or in the SPA is usually successful. TAE proximal to PHA must be restricted to cases where collateral hepatic blood flow exists. Otherwise or for a pseudoaneurysm of the superior mesenteric artery, endovascular stenting, temporary creation of an ileocolic arterioportal shunt, or vascular reconstruction by re-laparotomy is an alternative.

Duration of antimicrobial prophylaxis in patients undergoing hepatectomy: a prospective randomized controlled trial using flomoxef

OBJECTIVES

Although the usefulness of antimicrobial prophylaxis for clean-contaminated surgery has been recognized, only a few randomized controlled studies on the duration of administration after hepatectomy have been performed. We investigated the duration of antimicrobial prophylaxis after hepatectomy.

METHODS

The subjects were 180 patients who underwent hepatectomy without reconstruction of the biliary or intestinal tract between April 2003 and March 2006 at our department. The patients were randomly allocated to groups to be treated with flomoxef sodium as antimicrobial prophylaxis for 2 days (89 patients) or 5 days (91 patients), including the operation day. The presence or absence of systemic inflammatory response syndrome (SIRS) and infections was investigated.

RESULTS

No significant differences were noted in patient background between the two groups. Infections occurred in seven and six patients in the 2 day and 5 day treatment groups (7.9% and 6.6%), respectively, showing no significant difference between the two groups. No significant difference was noted when the cases were divided into surgical site infections and remote infections. The positive rate of SIRS was significantly higher in the 2 day treatment group than in the 5 day treatment group on days 2 and 3 after surgery. The risk factors in patients who developed infections were blood loss, operation time and the complication of biliary fistula.

CONCLUSIONS

Two day administration of flomoxef sodium may be sufficient for antimicrobial prophylaxis after hepatectomy. However, when SIRS is positive on post-operative day 2, and induction of liver failure is of concern, it may be safer to continue antimicrobial drug administration until SIRS is eliminated.

Outcomes of adult-to-adult living donor liver transplantation: a single institution's experience with 335 consecutive cases

OBJECTIVE

To determine outcomes for both donors and recipients of adult-to-adult living donor liver transplantation (AALDLT) and independent factors impacting those outcomes.

SUMMARY BACKGROUND DATA

Deceased donors for organ transplantation remain extremely rare, making living donor liver transplantation (LDLT) practically the sole therapeutic modality for patients with end-stage liver disease in Japan.

METHODS

Retrospective analysis of initial LDLT for 335 consecutive adult (>or=18 years) patients performed between November 1994 and December 2003.

RESULTS

: Of the 335 recipients, 275 received right-liver grafts and the remaining 60 recipients received non-right-liver grafts. Three of the 335 liver grafts were domino-splitting livers. Sixty of the 332 donors other than the domino-donors showed major postoperative complications. Multivariate analysis indicated that accumulation of case experience significantly and advantageously affected the surgical outcomes of these living liver donors, and right-liver donation and prolonged donor operation time were shown to be independent risk factors of major complications in the donors. Post-transplant patient and graft survival estimates were 73.1% and 72.5% at 1 year, 67.7% and 66.3% at 4 years, and 64.7% and 61.9% at 7 years, respectively. Obvious pretransplant encephalopathy, a higher (>or=31) modified Model for End-stage Liver Disease score (including points for persistent ascites and low serum sodium) and higher donor age (>or=50 years) were indicated as independent factors predictive of graft failure (graft loss or death) in the multivariate analysis.

CONCLUSIONS

Graft type and degree of experience exerted a significant impact on the surgical outcomes of AALDLT donors but did not significantly affect the survival outcomes of AALDLT recipients. Better pretransplant conditions and younger age (<50 years) among the living donors appeared to be advantageous in terms of gaining better survival outcomes of patients undergoing AALDLT.

Impact of human leukocyte antigen mismatching on outcomes of living donor liver transplantation for primary biliary cirrhosis

Patient selection criteria of deceased donor liver transplantation for primary biliary cirrhosis (PBC) are almost completely established. The aim of this study was to establish selection criteria for both patients and donors of living donor liver transplantation (LDLT) for PBC. We used univariate and multivariate analyses to examine patient and donor characteristics of our first 50 cases of LDLT for PBC to elucidate factors that significantly impacted patient survival or disease recurrence after LDLT in the univariate and/or multivariate analyses. Multivariate analysis demonstrated that the presence of persistent ascites before LDLT, a higher number of human leukocyte antigen (HLA)-A, -B, and -DR mismatches between donor and recipient, and donor age >or=50 years were factors significantly associated with early posttransplant death. Independent risk factors for PBC recurrence after LDLT were a lower number of HLA mismatches between donor and recipient, and a lower average trough level of tacrolimus within 1 year after LDLT. Specifically, the lower the number of HLA-A, -B, and -DR mismatches or the average trough level of tacrolimus within 1 year after LDLT, the higher the possibility of developing a recurrence of PBC. In conclusion, the absence of persistent ascites before LDLT, a lower number of HLA-A, -B, and -DR mismatches between donor and recipient, and a younger donor (<50 years) are preferred for gaining acceptable survival outcomes for the transplant. However, a lower number of HLA-A, -B, and -DR mismatches between donor and recipient may be a risk factor for PBC recurrence.

Results of living donor liver transplantation in five children with congenital cardiac malformations requiring cardiac surgery

In the pediatric population, the concomitant presentation of end-stage liver disease and congenital cardiac malformation occurs rarely. Determining the surgical priority in these cases is a challenge due to the presence of hemodynamic alterations that increase surgical risks. We examined five cases that received living-donor liver transplantation. In four patients that had congenital heart disease with a left to right shunt, two had cardiac surgery first, one had both heart and liver surgery simultaneously, and one underwent liver transplantation first. Both of the patients that received heart surgery before liver transplantation needed emergency liver transplantation because of post-operative liver failure. All five patients had a good outcome. Meticulous surgery, close monitoring, and adequate volume management, in addition to tailoring management decisions to the patient's specific condition, make it possible to correct both the liver and the heart abnormalities with satisfactory results.

Disruption of the Middle Hepatic Vein is not Crucial for Liver Regeneration of the Remnant Liver After Right Hemihepatectomy for Hepatic Tumors

BACKGROUND

To clarify the role of the middle hepatic vein (MHV) in liver regeneration of the remnant liver after right hemihepatectomy for hepatic tumors, we reviewed 29 patients to evaluate liver regeneration for up to 12 postoperative months.

METHODS

Volume regeneration of the remnant liver was investigated by computed tomography at 3, 6, and 12 postoperative months. The remnant liver was divided into the following three areas: the medial section (segment IV), the lateral section (segments II and III), and segment I. The patients were divided into two groups: group A (n = 17), in which the MHV was preserved in the remnant liver, and group B (n = 12), in which the MHV was removed.

RESULTS

Volume regeneration of each area continued until 6 postoperative months but did not increase thereafter. On univariate analysis, differences in the volume regeneration of each area between the groups were not significant at any measured time point. Furthermore, disruption of the MHV was determined to not be crucial to the volume regeneration of any liver area on multivariate analysis. Only the resection volume (percentage) significantly affected liver regeneration of the remnant liver.

CONCLUSIONS

Disruption of the MHV does not decisively affect liver regeneration of remnant liver after right hemihepatectomy for hepatic tumors.

Long-term outcome of adult-to-adult living donor liver transplantation for post-Kasai biliary atresia

Our objective was to analyze problems in the perioperative management and long-term outcome of living donor liver transplantation (LDLT) for biliary atresia (BA). Many reports have described the effectiveness of liver transplantation (LT) for BA, particularly in pediatric cases, but little information is available regarding LT in adults (> or =16 years old). Between June 1990 and December 2004, 464 patients with BA underwent LDLT at Kyoto University Hospital, of whom 47 (10.1%) were older than 16 years. In this study, we compared the outcomes between adult (> or =16 years old) and pediatric (<16 years old) patients. The incidence of post-transplant intestinal perforation, intra-abdominal bleeding necessitating repeat laparotomy and biliary leakage was significantly higher (p < 0.0001, <0.001 and <0.001, respectively) in adults. Overall cumulative 1-, 5- and 10-year survival rates in pediatric patients were significantly higher (p < 0.005) than in adults. Two independent prognostic determinants of survival were identified: a MELD score over 20 and post-transplant complications requiring repeat laparotomy. Outcome of LDLT in adult BA patients was poorer than in pediatric patients. It seems likely that LT will be the radical treatment of choice for BA and that LDLT should be considered proactively at the earliest possible stage.

Applicability of the Milan Criteria for Determining Liver Transplantation as a First-Line Treatment for Hepatocellular Carcinoma

BACKGROUND

To determine whether or not the Milan criteria (MC) should be used to determine the applicability of liver transplantation (LT) as a first-line treatment for patients with cirrhosis with hepatocellular carcinoma (HCC) who are able to endure hepatectomy.

METHODS

Retrospective analysis of 82 patients with cirrhosis with HCC who were treated by hepatectomy without LT at our institution between 1990 and 2003.

RESULTS

Of these 82 patients, 48 met the MC. Proportional hazard regression analyses to determine the independent prognostic factors for postoperative cumulative patient and disease-free survival showed that meeting the MC is the strongest prognostic factor for both patient and disease-free survival. The cumulative patient and disease-free survival rates were 76.7% and 28.9%, respectively, at 5 years in patients who met the MC. The cumulative disease-free survival was markedly inferior to those in previously reported series of LT for HCC who met the MC, but the cumulative patient survival was comparable to those in the previously reported series. A comparison of cumulative postoperative survival between patients who met the MC and fulfilled all five factors listed below and patients who met the MC but did not fulfill any of the five factors demonstrated that the latter patients showed statistically significantly worse postoperative patient survival than the former. The five factors included: Model for End-Stage Liver Disease score < 10, indocyanine green retention rate at 15 minutes < 20%, absence of microscopic fibrous capsular invasion and microscopic intrahepatic metastases, and earlier grade (T1 or T2) of American Joint Committee on Cancer tumor classification.

CONCLUSIONS

The MC should not be used to determine the applicability of LT as a first-line treatment for patients with HCC considered able to endure hepatectomy. However, modifying MC with some clinicopathological factors could satisfy the appropriate criteria for applying LT as a first-line treatment for these patients.

Vascular reconstruction and complications in living donor liver transplantation in infants weighing less than 6 kilograms: the Kyoto experience

Smaller-size infants undergoing living-donor liver transplantation (LDLT) are at increased risks of vascular complications because of their smaller vascular structures in addition to vascular pedicles of insufficient length for reconstruction. Out of 585 child patients transplanted between June 1990 and March 2005, 64 (10%) weighing less than 6 kg underwent 65 LDLTs. Median age and weight were 6.9 months (range: 1-16 months) and 5 kg (range: 2.8-5.9 kg), respectively. Forty-five lateral segment, 12 monosegment, and 8 reduced monosegment grafts were adopted, and median graft-to-recipient weight ratio was 4.4% (range: 2.3-9.7). Outflow obstruction occurred in only 1 patient (1.5%). Portal vein complication occurred in 9 (14%) including 5 with portal vein thrombosis. Hepatic artery thrombosis (HAT) occurred in 5 (7.7%). Patient and graft survivals were 73% and 72% at 1 yr, and 69% and 68% at 5 yr after LDLT, respectively. Thirteen of 22 grafts (58%) lost during the follow-up period occurred within the first 3 months posttransplantation. Overall graft survival in patients with and without portal vein complication was 67% and 65%, respectively (P = 0.54). Overall graft survival in patients with and without HAT was 40% and 67%, respectively. HAT significantly affected graft survival (P = 0.04). In conclusion, our surgical technique for smaller-size recipients resulted in an acceptable rate of vascular complications. Overcoming early posttransplantation complications will further improve outcomes in infantile LDLT.

Prognostic significance of the number of positive lymph nodes in gallbladder cancer

The aim of this study was to assess the prognostic impact of the number of lymph node metastases. The medical records of 33 patients with node-positive gallbladder cancer (GBC) treated at our institution from January 1985 through December 2002 were reviewed. There were 10 cases with a single node metastasis. The sites were as follows: the cystic duct node, the pericholedochal node, the retroportal node, the hilar node, the lymph node around the common hepatic artery, and the paraaortic node. According to the International Union Against Cancer (UICC) 5th edition, 5-year survival rates for the patients with pN1, pN2, and greater than pN2 were 19.2%, 10%, and 0%, respectively (not significant). Patients with a single node metastasis had a higher 5-year survival rate (33%) than patients with two or more lymph node metastases (0%; P < 0.05). There were no lymph node recurrences in patients with a single node metastasis. Number of positive nodes and liver metastasis were factors predictive of significantly worse survival. Rather than using the topographic classification, or even simply classifying whether nodal involvement is positive or negative, classification according to the number of positive nodes will contribute to establishing a more practically useful staging system.

[Standard surgery as part of the multidisciplinary treatment for pancreatic cancer]

Standardization of surgical procedure for pancreatic cancer has been recognized to be necessary and important these days. Recent studies appear to exhibit efficacy of the adjuvant chemoradiation therapy before or after pancreatic surgery. In this study, we examined the standard surgery as part of the multidisciplinary treatment for pancreatic cancer. Invasive ductal carcinoma of the pancreas was resected in 121 patients in our institution from 1992 through 2005. We stopped performing an extended lymphadenectomy with pancreatectomy in 2003, but the survival rates were not significantly different between the cases before and after 2003. We usually resect half of the nerve plexus around the superior mesenteric artery (SMA) as a standard procedure. When we achieved the microscopically curative resection (R0) even if the plexus around SMA or the portal vein was invaded, there were a few long survivors for more than five years. The R0 resection is the most important factor for prolonged survival. Pancreatectomy including removal of regional lymph nodes (D2) and half of the nerve plexus around SMA and combined resection of the infiltrated portal vein is thought to be a standard surgery from the viewpoint of decrease in morbidity and maintenance of curability.

A rat model of a repeat 70% major hepatectomy

BACKGROUND

This study investigated the effects of a repeat 70% major hepatectomy in a rat model.

MATERIALS AND METHODS

The left lateral and median lobes of the livers of 80 seven-week-old male Wistar rats were excised during primary hepatectomy, removing a total of 70% of the liver. In 40 of the rats, the regenerated right lateral lobe, comprising 70% of the remnant liver, was excised during secondary hepatectomy 7 days after the initial procedure. The survival rate, posthepatectomized regeneration ratio, and laboratory blood data were compared between the groups that had undergone initial only and repeat hepatectomies.

RESULTS

All of the rats survived for at least 7 days after each procedure. The remaining liver returned to up to about 90% of its original wet weight by 5 days in both groups. The serum glutamic-pyruvic transaminase levels peaked 12 h after hepatectomy, remained at a similar level at 36 h, and had normalized by 2 days. Serum total bilirubin levels were similar in both groups. The total cell numbers after 5 days were significantly higher in the initial hepatectomy group than in the repeat hepatectomy group.

CONCLUSIONS

We established a rat model in which an initial 70% major hepatectomy was followed by a repeat 70% major hepatectomy of the regenerated liver. The time taken to restore the integrity of the liver was longer in the rats that underwent repeat hepatectomy. We believe that this model will be useful for investigating the regenerative ability of the liver after a second major hepatectomy.

Safety limit of the extent of hepatectomy for rats with moderately fatty liver: experimental study concerning living liver donor safety

INTRODUCTION

The aim of the present study was to determine whether rats with moderately fatty liver could withstand a 90% hepatectomy, which rats with normal livers can survive.

MATERIAL AND METHODS

Nine-week-old male Wistar rats were used. Normal rat chow was fed to the normal liver group, and fat-enriched rat chow was fed to the fatty liver group for 4 weeks to induce a moderately fatty liver. The authors have previously reported that this fatty liver rat model can cause fatal liver dysfunction after reduced-size-liver transplantation. A 90% and 95% hepatectomy were performed using rats of both groups to evaluate posthepatectomized liver function.

RESULTS

All rats undergoing a 90% hepatectomy were still alive 30 days after the hepatectomy, but the rats that underwent a 95% hepatectomy were all dead within 4 days regardless of group. Increases in the liver remnant wet weight measured until 7 postoperative days after 90% hepatectomy were almost similar among the two groups. Alanin aminotransferase measured at 24, 48, 72, and 168 h after a 90% hepatectomy were significantly higher in the fatty liver group than in the normal liver group. Similarly, at up to 72 h postoperatively, the serum hyarulonic acids were significantly higher in the fatty liver group.

CONCLUSION

A moderately fatty liver did not cause mortality in 90% hepatectomized rats. However, it caused a higher degree of hepatic parenchymal as well as sinusoidal injury.

Current role of liver transplantation for the treatment of urea cycle disorders: a review of the worldwide English literature and 13 cases at Kyoto University

To address the current role of liver transplantation (LT) for urea cycle disorders (UCDs), we reviewed the worldwide English literature on the outcomes of LT for UCD as well as 13 of our own cases of living donor liver transplantation (LDLT) for UCD. The total number of cases was 51, including our 13 cases. The overall cumulative patient survival rate is presumed to be more than 90% at 5 years. Most of the surviving patients under consideration are currently doing well with satisfactory quality of life. One advantage of LDLT over deceased donor liver transplantation (DDLT) is the opportunity to schedule surgery, which beneficially affects neurological consequences. Auxiliary partial orthotopic liver transplantation (APOLT) is no longer considered significant for the establishment of gene therapies or hepatocyte transplantation but plays a significant role in improving living liver donor safety; this is achieved by reducing the extent of the hepatectomy, which avoids right liver donation. Employing heterozygous carriers of the UCDs as donors in LDLT was generally acceptable. However, male hemizygotes with ornithine transcarbamylase deficiency (OTCD) must be excluded from donor candidacy because of the potential risk of sudden-onset fatal hyperammonemia. Given this possibility as well as the necessity of identifying heterozygotes for other disorders, enzymatic and/or genetic assays of the liver tissues in cases of UCDs are essential to elucidate the impact of using heterozygous carrier donors on the risk or safety of LDLT donor-recipient pairs. In conclusion, LT should be considered to be the definitive treatment for UCDs at this stage, although some issues remain unresolved.

Living donor liver transplantation for pediatric patients with inheritable metabolic disorders

Forty-six pediatric patients who underwent living donor liver transplantation (LDLT) using parental liver grafts for inheritable metabolic disorders (IMD) were evaluated to determine the outcomes of the surgery, decisive factors for post-transplant patient survival and the impact of using donors who were heterozygous for the particular disorder. Disorders included Wilson disease (WD, n = 21), ornithine transcarbamylase deficiency (OTCD, n = 6), tyrosinemia type I (TTI, n = 6), glycogen storage disease (GSD, n = 4), propionic acidemia (PPA, n = 3), methylmalonic acidemia (MMA, n = 2), Crigler-Najjar syndrome type I (CNSI, n = 2), bile acid synthetic defect (BASD, n = 1) and erythropoietic protoporphyria (EPP, n = 1). The post-transplant cumulative patient survival rates were 86.8 and 81.2% at 1 and 5 years, respectively. Post-transplant patient survival and recovery of the growth retardation were significantly better in the liver-oriented diseases (WD, OTCD, TTI, CNSI and BASD) than in the non-liver-oriented diseases (GSD, PPA, MMA and EPP) and pre-transplant growth retardation disadvantageously affected post-transplant outcomes. Although 40 of 46 donors were considered heterozygous for each disorder, neither mortality nor morbidity related to the heterozygosis has been observed. LDLT using parental donors can be recommended as an effective treatment for pediatric patients with IMD. In the non-liver-oriented diseases, however, satisfactory outcomes were not obtained by hepatic replacement alone.

A good model of hepatic failure after excessive hepatectomy in mice

AIMS

This study was intended to establish in mice: 1) a safety limit for the extent of hepatectomy and 2) the extent of hepatectomy invariably causing fatal hepatic failure, to facilitate gene expression analysis.

MATERIALS AND METHODS

In 70%-hepatectomy, the left lateral and median lobes were removed, and in 90%-hepatectomy, all lobes except the caudate were resected. One-week survival rates, serum concentrations of aspartate aminotransferase, alanine aminotransferase and total bilirubin were measured. Histological examinations were performed using hematoxylin and eosin staining, and immunohistochemical tests were done with antibody against Ki-67 antigen.

RESULTS

All of the 70%-hepatectomized mice were alive at 1 week, but the 90%-hepatectomized mice all died within 24 h after hepatectomy. Serum aminotransferase and total bilirubin levels were significantly higher in the 90%-hepatectomized mice than in the 70%-hepatectomized mice. Liver histology revealed more prominent vacuolar degeneration in the former. Ki67-positive hepatocytes appeared and proliferated immediately after 70%-hepatectomy, but few were observed in the 70%-hepatectomized mice.

CONCLUSION

We established 90%-hepatectomy as the safety limit for murine hepatectomy and as a model for liver regeneration, and 90%-hepatectomy as a "fatal hepatic failure level."

Usefulness of granular BCAA after hepatectomy for liver cancer complicated with liver cirrhosis

OBJECTIVE

Nutritional disturbances such as ascites and hypoalbuminemia frequently arise after hepatectomy for liver cancer with liver cirrhosis. We examined the possibility of maintaining a favorable state of nutrition by outpatient administration of branched-chain amino acid (BCAA) granules.

METHODS

Forty-three patients who had gross liver cirrhosis complicated by liver cancer and underwent surgery up to May 2002 were given BCAA granules (n = 21, BCAA group) or no granules (n = 22, control group).

RESULTS

1) Background details such as age, sex, surgical technique, blood loss, and duration of surgery showed no significant differences. 2) Among objective findings, improvement of ascites and edema tended to occur sooner in the BCAA group, but without a significant difference. 3) Although serum albumin recovered its preoperative value 9 mo after surgery in the control group, only 6 mo was required for recovery in the BCAA group. Total protein showed similar changes, but neither group showed any difference in changes of aspartate aminotransferase, alanine transferase, or platelets. 4) One year postoperatively, the change from the preoperative indocyanine green retention rate at 15 min after intravenous administration tended to be worse in the control group, but not significantly so. 5) In the BCAA group, hyaluronic acid and type IV collagen 7S improved significantly sooner than in the control group.

CONCLUSIONS

BCAA supplementation after hepatectomy promotes rapid improvement in protein metabolism and inhibits progression to liver cirrhosis. Administration of BCAA after hepatectomy is considered beneficial to a patient's nutritional state.

Living Donor Liver Transplantation for Noncirrhotic Inheritable Metabolic Liver Diseases: Impact of the Use of Heterozygous Donors

BACKGROUND

In living donor liver transplantation (LDLT), the liver donor is almost always a blood relative; therefore, the donor is sometimes a heterozygous carrier of inheritable diseases. The use of such carriers as donors has not been validated. The aim of the present study was to evaluate the outcome of LDLT for noncirrhotic inheritable metabolic liver disease (NCIMLD) to clarify the effects of using a heterozygous carrier as a donor.

METHODS

Between June 1990 and December 2003, 21 patients with NCIMLD underwent LDLT at our institution. The indications for LDLT included type II citrullinemia (n = 7), ornithine transcarbamylase deficiency (n = 6), propionic acidemia (n = 3), Crigler-Najjar syndrome type I (n = 2), methylmalonic acidemia (n = 2), and familial amyloid polyneuropathy (n = 1). Of these 21 recipients, six underwent auxiliary partial orthotopic liver transplantation.

RESULTS

The cumulative survival rate of the recipients was 85.7% at both 1 and 5 years after operation. All surviving recipients are currently doing well without sequelae of the original diseases, including neurological impairments or physical growth retardation. Twelve of the 21 donors were considered to be heterozygous carriers based on the modes of inheritance of the recipients' diseases and preoperative donor medical examinations. All donors were uneventfully discharged from the hospital and have been doing well since discharge. No mortality or morbidity related to the use of heterozygous donors was observed in donors or recipients.

CONCLUSIONS

Our results suggest that the use of heterozygous donors in LDLT for NCIMLD has no negative impact on either donors or recipients, although some issues remain unsolved and should be evaluated in further studies.

Pharmacologic preconditioning effects: prostaglandin E1 induces heat-shock proteins immediately after ischemia/reperfusion of the mouse liver

Prostaglandin E1 (PGE1) has several potential therapeutic effects, including cytoprotection, vasodilation, and inhibition of platelet aggregation. This study investigates the protective action of PGE1 against hepatic ischemia/reperfusion injury in vivo using a complementary DNA microarray. PGE1 or saline was continuously administered intravenously to mice in which the left lobe of the liver was made ischemic for 30 minutes and then reperfused. Livers were harvested 0, 10, and 30 minutes postreperfusion. Messenger RNA was extracted, and the samples were labeled with two different fluorescent dyes and hybridized to the RIKEN set of 18,816 full-length enriched mouse complementary DNA microarrays. Serum alanine aminotransferase and aspartate aminotransferase levels at 180 minutes postreperfusion were significantly lower in the PGE1-treated group than in the saline-treated group. The cDNA microarray analysis revealed that the genes encoding heat-shock protein (HSP) 70, glucose-regulated protein 78, HSP86, and glutathione S-transferase were upregulated at the end of the ischemic period (0 minutes postreperfusion) in the PGE1 group. Our results suggested that PGE1 induces HSPs immediately after ischemia reperfusion. HSPs might therefore play an important role in the protective effects of PGE1 against ischemia/reperfusion injury of the liver.

Biliobiliary fistulas manifested by worsening liver function--a case report

We report a case of cholecystolithiasis with biliobiliary fistulas from gallbladder to hepatic ducts, which were manifested by worsening liver dysfunction. Although it was not diagnosed preoperatively, it was successfully treated by cholecystectomy with closure of fistulas by the gallbladder wall. This case suggests that an internal biliary fistula may be possible, when the gallbladder wall is thickened and shrunken in the case of cholecystolithiasis, accompanied with liver dysfunction despite no dilatation of the common bile duct.

Usefulness of artificial liver support for pretransplant patients with fulminant hepatic failure

This study assessed the usefulness of artificial liver support (ALS) for pretransplant patients with fulminant hepatic failure (FHF). Five patients (age 14 to 52 years, 3 men and 2 women) with FHF who were being prepared for living donor liver transplantation (LDLTx) were enrolled in this study. ALS included plasma exchange, using 40 to 50 units of fresh frozen plasma per session, and high-flow hemodiafiltration, using a high-performance polysulfone membrane. Variables such as circulatory and respiratory function, coma grade, and neurologic disorders were evaluated. Although systolic and diastolic blood pressures showed no statistical differences between pre-ALS and post-ALS, the difference in heart rates was statistically significant. After ALS initiation in the pre-LDLTx period, one of the three patients who needed mechanical ventilation was weaned from it. After LDLTx, all patients recovered neurologically; no neurologic disorder was observed. These results suggested that ALS could predict neurologic status after LDLTx. The difference in coma grades also achieved statistical significance. Our study indicates that short-term ALS is useful for improving circulatory and respiratory function prior to liver transplantation, as well as for predicting posttransplantation neurologic status. Although some patients recover by ALS alone, the survival rate of ALS-only patients is less than 50%. ALS prolongs intensive treatment, thus increasing both the risk of infection and the medical costs. Further investigation to determine a precise marker for liver regeneration will be needed to establish a consensus on the indications for long-term ALS. We conclude that ALS is useful to improve circulatory and respiratory functions among pretransplant patients, and to predict neurologic status after LDLTx.

Efficacy of hepatic resection for hepatocellular carcinomas larger than 10 cm

The objective of this study were to evaluate the efficacy of hepatic resection for large hepatocellular carcinomas (HCCs) and examine clinicopathologic factors influencing overall survival after resection of a large HCC. The pre-, intra-, and postoperative factors and long-term outcome of 26 patients with HCCs >10 cm who underwent hepatic resection (group A) were compared with the those of 143 patients with HCCs < or =10 cm (group B). Hepatic resection for large HCCs can be performed with a mortality rate of 3.8%, which was similar to the rate for group B (2.1%). The overall cumulative survival results for group A (1 year 41.0%, 3 years 29.3%, 5 years 29.3%; median survival 10.1 months) were markedly worse than those for group B (1 year 93.1%, 3 years 74.5%, 5 years 44.7%; median survival 53.4 months) (p < 0.0001). Multivariate analysis identified venous invasion as an independent risk factor of survival of patients with a large HCC. The overall cumulative survival results in patients with venous invasion (1 year 28.0%, 3 years 0%; median survival 6.4 months) were markedly worse than in patients without venous invasion (1 year 64.8%, 3.5 years 64.8%; median survival, 51.8 months) (p < 0.0066). We concluded that hepatic resection can be performed safely for HCCs >10 cm with a low mortality rate. It appears reasonable to believe that hepatic resection is the treatment of choice for large HCCs without venous invasion.

Two-stage hepatectomy for multiple bilobular liver metastases from colorectal cancer

BACKGROUND/AIMS

To determine an appropriate surgical treatment for patients with multiple liver metastases, we evaluated the efficacy of two-stage hepatectomy in patients with multiple bilobular liver metastases from colorectal carcinoma.

METHODOLOGY

Some patients with multiple liver metastases are not candidates for a complete resection by a single hepatectomy, even when downstaged by chemotherapy, after portal embolization. In two-stage hepatectomy, the highest possible number of tumors is resected in a first, noncurative intervention, and the remaining tumors are resected after a period of liver regeneration. Two-stage hepatectomy was performed in 11 patients.

RESULTS

Two-stage hepatectomy was feasible in all of the 11 patients. In 3 of them, the first stage was a major resection (more extensive than a lobectomy). This first hepatectomy was uneventful in all patients. The second hepatectomy was also uneventful in nine patients, but in one of the other two, a perihepatic fluid infection occurred, and in the other, postoperative liver failure developed due to a right subphrenic abscess. However, all patients were discharged. The percentage of the expected resection volume at one time, calculated from CT volumetry, was 75.5+/-1.2% and the prognostic score as surgical risk was 56.6+/-4.5. In two-stage hepatectomy cases, the percentage of the resected volume and the prognostic score in the first hepatectomy were 25.4+/-6.4% and 6.7+/-7.3, and in the second, 45.7+/-4.5% and 28.5+/-5.8. During the follow-up procedures, a residual hepatic recurrence was observed in 6 patients, and pulmonary recurrence in 9. The 1- and 3-year survival rates after the first hepatectomy were 90% and 45%, with median survivals of 18 months from the first hepatectomy.

CONCLUSIONS

Two-stage hepatectomy is a surgical modality intended for patients with initial unresectable metastases. However, following such surgery, protective treatment against residual liver recurrence and lung metastasis will be a most important issue.