The beneficial role of simultaneous splenectomy in living donor liver transplantation in patients with small-for-size graft

Small for Size and Flow (SFSF) syndrome: An alternative description for posthepatectomy liver failure

Small for Size Syndrome (SFSS) syndrome is a recognizable clinical syndrome occurring in the presence of a reduced mass of liver, which is insufficient to maintain normal liver function. A definition has yet to be fully clarified, but it is a common clinical syndrome following partial liver transplantation and extended hepatectomy, which is characterized by postoperative liver dysfunction with prolonged cholestasis and coagulopathy, portal hypertension, and ascites. So far, this syndrome has been discussed with focus on the remnant size of the liver after partial liver transplantation or extended hepatectomy. However, the current viewpoints believe that the excessive flow of portal vein for the volume of the liver parenchyma leads to over-pressure, sinusoidal endothelial damages and haemorrhage. The new hypothesis declares that in both extended hepatectomy and partial liver transplantation, progression of Small for Size Syndrome is not determined only by the "size" of the liver graft or remnant, but by the hemodynamic parameters of the hepatic circulation, especially portal vein flow. Therefore, we suggest the term "Small for Size and Flow (SFSF)" for this syndrome. We believe that it is important for liver surgeons to know the pathogenesis and manifestation of this syndrome to react early enough preventing non-reversible tissue damages.

A comparative study of two anti-coagulation plans on the prevention of PVST after laparoscopic splenectomy and esophagogastric devascularization

Cirrhosis and portal hypertension (PH) has a high incidence in China. Laparoscopic splenectomy and esophagogastric devascularization (LS + ED) was confirmed as an effective and safe surgical approach. But compared to open surgery (OS + ED), the rate of portal vein system thrombosis (PVST) was found to be higher after LS + ED. PVST is a common and potentially life-threatening complication after LS + ED in patients with cirrhosis and PH. Anti-coagulation therapy should be given early, but no standard plan for PSVT prophylaxis has been developed for all patients. In this study, the efficacy and safety of early use of low molecular weight heparin (LMWH) to prevent PVST were retrospectively evaluated compared with conventional anti-coagulant therapy. Of 219 patients with cirrhosis and PH undergoing LS + ED at our hospital from January 2008 to June 2013, 139 received early anti-coagulant therapy with LMWH, and 80 received conventional anti-coagulant therapy. The rates and types of PVST, perioperative coagulation function, intra-abdominal active bleeding, and esophagogastric variceal bleeding (EGVB) were compared in these two groups. Of the 139 patients in the early anti-coagulation group, 42 (30.2 %) experienced postoperative PVST, including two (1.4 %) with main trunk. Of the 80 patients in the conventional anti-coagulation group, 40 (50.0 %) experienced postoperative PVST, including 12 (15.0 %) with main trunk; three (3.8 %) experienced recurrent EGVB due to main trunk thrombosis, and one (1.3 %) underwent an immediate second laparotomy for uncontrollable active bleeding. The rates of postoperative PVST (P = 0.004), main trunk thrombosis (P = 0.000), and EGVB (P = 0.048) were significantly lower in the early than in the conventional anti-coagulant group, but all tested perioperative indices of coagulation function and rates of intraperitoneal active bleeding were similar. Early anti-coagulation with LMWH is safe and effective in patients with LS + ED for cirrhosis and PH.

Hepatic Hemodynamic Changes Following Stepwise Liver Resection

AIM

Extended liver resection has increased during the last decades. However, hepatic hemodynamic changes after resection and the consequent complications like post hepatectomy liver failure are still a challenging issue. The aim of this study was to systematically evaluate the role of stepwise liver resection on hepatic hemodynamic changes.

METHODS

To evaluate this effect we performed 25, 50, and 75 % sequential liver resections in 10 pigs. Before and after each resection, the hepatic artery flow and portal vein flow in relation to the remnant liver volume (RLV) as well as hepatic vascular pressures were measured and compared between the groups.

RESULTS

Following sequential liver resection, the hepatic artery flow /100 g decreases and the portal vein flow increases up to 17 and 167 % following extended liver resection (75 %), respectively. Also, during stepwise liver resection, the portal vein pressure increases gradually up to 33 % following extended hepatectomy (75 %).

CONCLUSION

Sequential decrease in the RLV decreases the hepatic artery flow /100 g and increases the portal vein flow /100 g and portal vein pressure. As the consequence, the liver goes under more poor-oxygenated blood supply and higher pressure. This may be one of the most important mechanisms of the post hepatectomy liver failure in case of extended liver resection.

Outcomes of adult-to-adult living donor liver transplantation in 321 recipients

We conducted a retrospective investigation in order to clarify whether selecting the type of liver graft had an impact on outcomes of adult-to-adult living donor liver transplantation (AALDLT). Data from the medical records of the donors and the recipients of 321 consecutive cases of AALDLT performed between April 2004 and March 2014 were retrospectively analyzed. Our general criteria for selecting the type of liver graft was that a left graft was preferentially selected when the estimated volume of the left graft was ≥35% of the standard liver volume of the recipient, and that a right graft was selected only when the estimated remnant liver volume of the donor was ≥35% of the total liver volume. In this series, 177 left grafts, 136 right grafts, and 8 posterior grafts were used. The left grafts tended to have 2 or more arteries, whereas the right grafts tended to have 2 or more bile duct orifices. The graft survival curves and the incidences of severe complications were comparable between the AALDLT using right grafts and the AALDLT using left grafts. The preoperative estimation of graft size hardly enabled us to predict severe posttransplant complication. Moreover, small-for-size graft syndrome occurred regardless of the estimated graft volumes. Instead, donor age was a significant risk factor for small-for-size graft syndrome. In conclusion, left grafts should be more aggressively used for the sake of donors' safety. The use of hepatic grafts from older donors should be avoided if possible in order to circumvent troublesome posttransplant complications.

Liver failure posthepatectomy and biliary fistula: multidisciplinar treatment

The main cause of morbimor-mortality after major liver surgery is the development of liver failure posthepatectomy(LFPH). Treatment must involve multiple options and will be aggressive from the beginning. We report a case of a patient with cholangiocarcinoma perihilar treated with surgery: right hepatectomy extended to sI + IVb with develop of LFPH and biliary fistula and being management successfully in a multidisciplinary way.

The role of adult living donor liver transplantation and recent advances

Twenty years since the first cases were described, adult living donor liver transplantation (ALDLT) is now considered a valid option to expand the donor pool in view of the ongoing shortage of organs and the high waiting list mortality rate. Despite the rapid evolution and acceptance of this complex process of donation and transplantation in clinical practice, the indications, outcome, ethical considerations and quality and safety aspects continue to evolve based on new data from large cohort studies. This article reviews the surgical and clinical advances in the field of liver transplantation, focusing on technical refinements and discussing the issues that may lead to a further expansion of this complex surgical procedure and the role of ALDLT.

The Influence of Aging on Hepatic Regeneration and Early Outcome after Portal Vein Occlusion: A Case-Control Study

BACKGROUND

Portal vein occlusion (PVO) is used to increase inadequate future liver remnant volume (FLRV). Impaired liver regeneration has been reported in aged animals. This study was designed to evaluate the impact of patient age on hepatic regeneration.

METHODS

Sixty patients aged ≥70 years were matched 1:1 with 60 patients aged <70 years. Matching criteria were sex, diabetes, cirrhosis, pre-PVO chemotherapy and bevacizumab administration, and jaundice.

RESULTS

The median ages in the older and younger groups were 76 (range 70-83) years and 59 (range 20-69) years, respectively (p < 0.001). Median FLRV following PVO (33.1 ± 6.8 vs. 31.9 ± 6.0 %) and volumetric increase (0.52 ± 0.35 vs. 0.49 ± 0.34) were similar in the two groups. Of the older and younger patients, 10 % and 1.7 %, respectively, did not undergo liver surgery after PVO (p = 0.051). Mortality (5.5 vs. 6.7 %) and major morbidity (25.9.8 vs. 22 %) rates were similar. Liver failure rate was higher in older patients (35.1 vs. 16.9 %, p < 0.026), mainly due to Grade A liver failure (20.3 vs. 8.4 %, p < 0.001). Multivariate analysis showed that age ≥ 70 years [odds ratio (OR) 3.03; 95 % confidence interval (CI) 1.18-7.78; p = 0.020] and biliary cancer diagnosis (OR 4.69; 95 % CI 1.81-12.09; p = 0.001) were independent risk factors for postoperative liver failure.

CONCLUSIONS

Liver regeneration after PVO is not impaired by age. Nevertheless, liver resection in elderly patients is performed less often after PVO and carries a higher risk of liver failure.

Clinical efficacy of simultaneous splenectomy in liver transplant recipients with hepatitis C virus

BACKGROUND

Interferon (IFN) therapy is a well-established antiviral treatment for hepatitis C virus (HCV) - infected patients. However, susceptibility to thrombocytopenia is a major obstacle in its initiation or continuation, particularly in patients with HCV who underwent liver transplantation (LT). We previously showed that the coexistence of splenomegaly and thrombocytopenia could result in persistent thrombocytopenia after LT. Here we retrospectively evaluated the validity of this criterion for simultaneous splenectomy in recipients with HCV.

PATIENTS AND METHODS

Subjects included 36 recipients with HCV who received LT between January 2006 and February 2012 at Hiroshima University. We analyzed the spleen volume, body surface area, platelet (PLT) count, and rate of completion or continuation with IFN therapy in these recipients.

RESULT

Of these recipients, 30 did not require simultaneous splenectomy according to the criterion, and 24 actually did not receive simultaneous splenectomy. In this group, 21 (87.5%) started IFN therapy. Fifteen (71.4%) of these recipients completed or continued IFN therapy, whereas 13 (61.9%) achieved either a sustained virological response (SVR) or an end-of-treatment response. The PLT count increased to >100,000/mm(3) 1 month after LT in 16 (66.7%) recipients from this group.

CONCLUSION

Our criterion detected the PLT count outcome after LT in recipients with HCV and achieved a better SVR result after IFN therapy.

Effect of laparoscopic splenectomy on portal haemodynamics in patients with liver cirrhosis and portal hypertension

BACKGROUND

The effect of splenomegaly in patients with liver cirrhosis and portal hypertension is not fully understood. This study was designed to determine the effect of laparoscopic splenectomy on portal haemodynamics in these patients.

METHODS

Patients with liver cirrhosis and portal hypertension who underwent laparoscopic splenectomy in Kyushu University Hospital from January 2006 to March 2009 were evaluated retrospectively. Correlations between splenic size and portal haemodynamics, and changes in portal haemodynamics and in levels of the vasoactive agents endothelin (ET) 1 and nitric oxide metabolites (NOx) before and 7-10 days after laparoscopic splenectomy were analysed.

RESULTS

Portal venous (PV) blood flow, PV cross-sectional area and PV congestion index correlated significantly with splenic size (P < 0·050). All three were significantly reduced following splenectomy in 59 patients. The hepatic venous pressure gradient, measured in 18 patients, decreased by 25 per cent after splenectomy (P < 0·001). Portal vascular resistance was also reduced, by 21 per cent (P = 0·009). The peripheral blood concentration of ET-1 decreased from 2·95 to 2·11 pg/ml (P < 0·001), and that of NOx tended to decrease (from 29·2 to 25·0 pg/ml; P = 0·068). In hepatic venous blood, the level of ET-1 decreased from 2·37 to 1·83 pg/ml (P = 0·006), whereas NOx concentration tended to increase (from 24·5 to 30·9 pg/ml; P = 0·067).

CONCLUSION

In patients with liver cirrhosis and portal hypertension, splenectomy reduced portal venous pressure. A decrease in splanchnic blood flow, by eliminating splenic blood flow, and reduction in intrahepatic vascular resistance, by normalizing hepatic concentrations of ET-1 and NOx, may both have contributed.

Optimizing risk stratification in portal vein thrombosis after splenectomy and its primary prophylaxis with antithrombin III concentrates and danaparoid sodium in liver cirrhosis with portal hypertension

BACKGROUND

Decreased antithrombin III (ATIII) activity and large splenic vein diameter (SVD) are risk factors for portal vein thrombosis (PVT) after splenectomy in liver cirrhosis with portal hypertension. Antithrombin III concentrates can prevent PVT. This study was designed to stratify risks for PVT after splenectomy in cirrhotic patients and to develop prophylactic protocols for PVT.

STUDY DESIGN

In 53 patients (testing cohort), the cutoff level of preoperative ATIII activity (≤60%) was evaluated for administration of ATIII concentrates. Antithrombin III activity and SVD were re-evaluated as criteria for prophylaxis of PVT. In 57 patients (validation cohort), the risk stratification of PVT and prophylactic protocols were validated.

RESULTS

In the testing cohort, 10 (19%) of 53 patients had PVT. Risk level of PVT was stratified and prophylactic protocols were developed. Patients at low risk (ATIII activity ≥70% and SVD <10 mm) were not treated; those at high risk (ATIII activity <70% or SVD ≥10 mm) received ATIII concentrates (1,500 U/day) for 3 days; and those at highest risk (SVD ≥15 mm) received ATIII concentrates for 3 days, followed by danaparoid sodium (2,500 U/day) for 14 days and warfarin. In the validation cohort, 0 of 14 low-risk and 2 of 32 high-risk patients had PVT. Although 8 of 11 patients at highest risk had temporary PVT, it disappeared within 3 months postoperatively. Finally, only 2 (3.5%) of 57 patients had PVT.

CONCLUSIONS

Risk stratification of PVT after splenectomy and prophylaxis with ATIII concentrates and danaparoid sodium dramatically reduced the incidence of PVT.

Small-for-size syndrome in living-donor liver transplantation using a left lobe graft

In living-donor liver transplantation with a left lobe graft, which can reduce the burden on the donor compared to right lobe graft, the main problem is small-for-size (SFS) syndrome. SFS syndrome is a multifactorial disease that includes aspects related to the graft size, graft quality, recipient factors and even technical issues. The main pathophysiology of SFS syndrome is the sinusoidal microcirculatory disturbance induced by shear stress, which is caused by excessive portal inflow into the smaller graft. The donor age, the presence of steatosis of the graft and a poor recipient status are all risk factors for SFS syndrome. To resolve SFS syndrome, portal inflow modulation, splenectomy, splenic artery modulation and outflow modulation have been developed. It is important to establish strict criteria for managing SFS syndrome. Using pharmacological interventions and/or therapeutic approaches that promote liver regeneration could increase the adequate outcomes in SFS liver transplantation. Left lobe liver transplantation could be adopted in Western countries to help resolve the organ shortage.

Clinical significance of gastrointestinal bleeding after living donor liver transplantation

The clinical presentations of gastrointestinal bleeding (GIB) occurring after living donor liver transplantation (LDLT) have not been fully described. We performed a retrospective analysis of 297 LDLT cases. Nineteen patients (6.4%) experienced GIB after LDLT. The etiology of GIB included bleeding at the jejunojejunostomy following hepaticojejunostomy (n = 13), peptic ulcer disease (n = 2), portal hypertensive gastropathy (n = 2), and other causes (n = 2). Hemostasis was achieved in 13 patients (68.4%) by endoscopic (n = 3), surgical (n = 1), or supportive treatments (n = 15), but not in the other six patients. Graft dysfunction (P < 0.001), hepaticojejunostomy (P = 0.01), portal vein pressure at the end of surgery >20 mmHg (P = 0.002), and operative blood loss >10 L (P = 0.004) were risk factors. One-year graft survival rate was significantly lower in patients with GIB than in patients without GIB (P < 0.001). The inhospital mortality rate was 52.6% for patients with GIB, 75.0% for patients with graft dysfunction, and 14.3% for patients without graft dysfunction (P = 0.028). Despite its infrequency after LDLT, GIB has strong correlation with graft dysfunction and inhospital mortality.

Simultaneous splenectomy during liver transplantation augments anti-viral therapy in patients infected with hepatitis C virus

BACKGROUND

Simultaneous splenectomy in liver transplantation (LT) is selectively indicated because of splenoportal venous thromboses and increased sepsis. Therefore, its impact should be further investigated.

METHODS

Of the 160 liver transplant patients, only 40 underwent simultaneous splenectomy. Clinicopathologic characteristics and outcomes were compared between the splenectomy and non-splenectomy group using retrospective analysis.

RESULTS

Although the groups were similar and had no significant difference in the intra- and postoperative data, non-splenectomy group had more male patients. However, splenectomy group showed significantly higher platelet and leukocyte counts at 1 month and 6 months after the transplantation and higher hepatitis C virus anti-viral therapy completion. Furthermore, 3 patients developed portal or splenic vein thrombosis during the postoperative follow-up, but the overall survival rate did not significantly differ between these groups.

CONCLUSION

Simultaneous splenectomy in LT can be safely performed, particularly in patients with hepatitis C virus cirrhosis, small-for-size grafts, hypersplenism, and ABO blood group incompatible (ABO - incompatible) LT.

Prolonged thrombocytopenia after living donor liver transplantation is a strong prognostic predictor irrespective of splenectomy: the significance of ADAMTS13 and graft function [corrected]

The precise mechanism of prolonged thrombocytopenia following living donor liver transplantation (LDLT) remains unclear. To determine risk factors associated with prolonged thrombocytopenia following LDLT, with a focus on the activity of ADAMTS13 (a disintegrin-like and metalloproteinase with thrombospondin type-1 motifs member 13) and the influence of splenectomy. Adult LDLT patients were divided into two groups on the basis of platelet counts (100 × 10(3)/μL) on POD 14: high and low platelet (HP and LP) groups. Survival analysis was performed in the 100 patients, and ADAMTS13 activity and von Willebrand factor (VWF) levels in the plasma were measured in 65 adult recipients. The 6-month survival rate was significantly lower in the LP group (n = 36) than in the HP group (n = 62) (61.1 vs. 93.5 %). ADAMTS13 activity had been significantly lower in the LP group (n = 23) than in the HP group (n = 42). The VWF/ADAMTS13 ratio was significantly higher in the LP group than in the HP group. The independent risk factors for thrombocytopenia on POD14 were preoperative AT levels and ADAMTS13 activity on POD14. TPO levels on POD14 were significantly higher in the LP group than in the HP group, while those on POD28 in the LP group were significantly decreased, despite the low platelet levels. Irrespective of splenectomy, platelet counts and ADAMTS13 activity in the LP group remained low until POD28, while VWF/ADAMTS13 ratio significantly increased until POD28. These results suggest that prolonged thrombocytopenia after LDLT was associated with not only a decrease in ADAMTS13 due to sinusoidal endothelial cell injury, but also low TPO production due to hepatocyte dysfunction, irrespective of splenectomy [corrected].

Re-evaluation of the predictive score for 6-month graft survival in living donor liver transplantation in the modern era

The limitations of donor age, graft size, and the Model for End-Stage Liver Disease (MELD) score have not been apparent in living donor liver transplantation (LDLT). Our team developed a formula for predicting graft survival after LDLT; the formula includes the graft weight, donor age, MELD score, and portosystemic shunt status. The aims of this study were to re-evaluate the reliability of our formula and to assess whether our modified treatment strategy has improved 6-month graft survival. Two hundred seventeen patients were allocated into 2 groups: patients with predictive scores ≥ 1.30 (n = 162) and patients with predictive scores < 1.30 (n = 55). The latter group was also divided into subgroups of patients with scores of 1.15 to 1.30 (n = 37) and patients with scores < 1.15 (n = 18). Survival rates for patients with scores < 1.30 were significantly worse than rates for patients with scores ≥ 1.30 (P = 0.006). Survival rates for patients with scores < 1.15 were significantly worse than rates for patients with scores of 1.15 to <1.30 (P < 0.001). A multivariate analysis showed that a predictive score < 1.15 (odds ratio = 7.87, P = 0.006) and a body mass index ≥ 30 kg/m(2) (odds ratio = 13.3, P < 0.001) were independent risk factors for 6-month graft mortality. In conclusion, predictive scores reliably predict 6-month graft survival and could allow a widening of the safe ranges for donor ages and graft sizes.

Early Graft Dysfunction in Living Donor Liver Transplantation and the Small for Size Syndrome

LDLT has arisen as a viable means to reduce waitlist mortality. However, its widespread embrace by the liver transplant community has been met with frustration centered on donor morbidity and small-for-size-syndrome. Focusing on the later entity, we describe the initial recognition of this early graft dysfunction, the theorized pathophysiology and solutions to remedy its emergence.

Outcome of patients undergoing right lobe living donor liver transplantation with small-for-size grafts

AIM: To investigate the outcome of living donor liver transplantation (LDLT) recipients transplanted with small-for-size grafts (SFSGs).

METHODS: Between November 2001 and December 2010, 196 patients underwent LDLT with right lobe liver grafts at our center. Recipients were divided into 2 treatment groups: group A with an actuarial graft-to-recipient weight ratio (aGRWR) < 0.8% (n = 45) and group B with an aGRWR ≥ 0.8% (n = 151). We evaluated serum liver function markers within 4 wk after transplantation. We also retrospectively evaluated the outcomes of these patients for potential effects related to the recipients, the donors and the transplantation procedures based upon a review of their medical records.

RESULTS: Small-for-size syndrome (SFSS) developed in 7 of 45 patients (15.56%) in group A and 9 of 151 patients (5.96%) in group B (P = 0.080). The levels of alanine aminotransferase and aspartate aminotransferase in group A were higher than those in group B during early period after transplantation, albeit not significantly. The cumulative 1-, 3- and 5-year liver graft survival rates were 82.22%, 71.11% and 71.11% for group A and 81.46%, 76.82%, and 75.50% for group B patients, respectively (P = 0.623). However, univariate analysis of risk factors associated with graft survival in group A demonstrated that the occurrence of SFSS after LDLT was the only significant risk factor affecting graft survival (P < 0.001). Furthermore, multivariate analysis of our data did not identify any additional significant risk factors accounting for poor graft survival.

CONCLUSION: Our study suggests that LDLT recipients with an aGRWR < 0.8% may have liver graft outcomes comparable to those who received larger size grafts. Further studies are required to ascertain the safety of using SFSGs.

Hemodynamic changes in the hepatic circulation after the modulation of the splenic circulation in an in vivo human experimental model

Recent advances in liver surgery have highlighted the effects of the splenic circulation on the hepatic circulation with respect to the hepatic arterial buffer response (HABR). The aim of the present study was to investigate the actual hemodynamic effects of splenic artery embolization/ligation and splenectomy on the hepatic circulation in patients who underwent pancreaticoduodenectomy through in vivo experimental models. In vivo models of splenic artery embolization/ligation (only splenic artery clamping) and splenectomy (simultaneous clamping of both the splenic artery and the splenic vein) were created in 40 patients who underwent pancreaticoduodenectomy for various reasons. The portal venous flow velocity, the portal venous flow volume, the hepatic arterial flow velocity, and the hepatic arterial resistance index were measured with color Doppler ultrasonography. Clamping of the splenic artery induced an immediate and significant increase (16%) in the hepatic artery velocity (P < 0.001), and the portal venous flow also decreased significantly (10%, P = 0.03). Fifteen minutes after the clamping of the splenic artery, the hepatic artery velocity remained significantly increased at the level of the initial clamping, and the portal venous flow significantly decreased (16%, P < 0.001). Clamping of the splenic vein, which was performed after the clamping of the splenic artery, resulted in an immediate and significant decrease (30%) in the portal venous flow (P < 0.001), but the hepatic arterial flow was not affected. Fifteen minutes after the clamping of the splenic vein, there was no change in the portal flow, which remained significantly lower (28%) than the flow in controls, whereas the hepatic arterial flow further significantly increased (31%, P < 0.001). In conclusion, our findings indicate that both splenic artery embolization/ligation and splenectomy are effective for increasing hepatic arterial flow and decreasing portal flow, with splenectomy providing a greater advantage. The HABR underlies these hemodynamic changes.

Liver function impairment in liver transplantation and after extended hepatectomy

Extended hepatectomy, or liver transplantation of reduced-size graft, can lead to a pattern of clinical manifestations, namely “post-hepatectomy liver failure” and “small-for-size syndrome” respectively, that can range from mild cholestasis to irreversible organ non-function and death of the patient. Many mechanisms are involved in their occurrence but in the recent past, high portal blood flow through a relatively small liver vascular bed has taken a central role. Therefore, several techniques of inflow modulation have been attempted in cases of portal hyperperfusion first in liver transplantation, such as portocaval shunt, mesocaval shunt, splenorenal shunt, splenectomy or ligation of the splenic artery. However, high portal flow is not the only factor responsible, and before major liver resections, preoperative assessment of the residual liver function is necessary. Techniques such as portal vein embolization or portal vein ligation can be adopted to increase the future liver volume, preventing post-hepatectomy liver failure. More recently, a new surgical procedure, that combines in situ splitting of the liver and portal vein ligation, has gradually come to light, inducing remarkable hypertrophy of the healthy liver in just a few days. Further studies are needed to confirm this hypothesis and overcome one of the biggest issues in the field of liver surgery.

Hepatic vein waveform and splenomegaly predict improvement of prothrombin time after splenectomy in hepatitis C virus-related cirrhotic patients

AIM

Whether hepatic function can recover in cirrhotic patients after splenectomy remains controversial.

METHODS

All consecutive Japanese patients with hepatic cirrhosis due to hepatitis C who had undergone elective splenectomy in Kyushu University Hospital between January 2008 and December 2009 were included in this retrospective study. Prothrombin time, serum albumin and total bilirubin concentrations were reviewed before and after splenectomy and analyzed to clarify whether splenectomy improves hepatic function in patients with cirrhosis and to determine the factors predictive of improvement in hepatic function.

RESULTS

Prothrombin time and total serum bilirubin concentration improved after splenectomy; however, serum albumin concentrations did not increase significantly. Twelve months after splenectomy, total serum bilirubin had decreased by over 0.3 mg/dL in 52.3% of patients and prothrombin time had improved by over 10% in 52.3% of patients. Multiple linear regression analysis identified hepatic vein waveform (HVWF) type I (P = 0.0174) and spleen weight (P = 0.0394) as independent predictors of improvement in prothrombin time and preoperative total serum bilirubin (P = 0.0002) as the only independent predictor of decrease in total bilirubin. Total bilirubin and prothrombin time were significantly improved after splenectomy in patients with HVWF type I, however, they were not improved in patients with HVWF type II.

CONCLUSION

Prothrombin time and total bilirubin improve in approximately half of cirrhotic patients within a year after splenectomy. HVWF type I and splenomegaly may be predictive factors for improvement in prothrombin time after splenectomy in patients with cirrhosis due to hepatitis C.

Impact of tumor size, number of tumors and neutrophil-to-lymphocyte ratio in liver transplantation for recurrent hepatocellular carcinoma

AIM

Hepatocellular carcinoma (HCC) is primarily treated with hepatic resection and/or locoregional therapy. When HCC recurs and further treatment is no longer possible owing to poor liver function, liver transplantation (LT) or living-donor LT (LDLT) is considered. The aim of this study was to clarify risk factors for tumor recurrence after LDLT in patients with recurrent HCC.

METHODS

The study comprised 104 patients who had undergone LDLT because of end-stage liver disease with recurrent HCC. The recurrence-free survival rates after the LDLT were calculated. Risk factors for tumor recurrence were identified.

RESULTS

The 1-, 3- and 5-year recurrence-free survival rates were 89.6%, 80.3% and 78.4%, respectively. By univariate analysis, the factors affecting recurrence-free survival were the sum of the largest tumor size and number of tumors of 8 or more (P < 0.0001), des-γ-carboxy prothrombin of more than 300 mAU/mL (P = 0.0001), and a neutrophil-to-lymphocyte ratio (NLR) of 4 or more (P = 0.0002), α-fetoprotein of more than 400 ng/mL (P = 0.0001) and bilobar tumor distribution (P = 0.046). A multivariate analysis identified independent risk factors for post-LDLT tumor recurrence including the sum of tumor size and number of tumors of 8 or more (P = 0.0004) and an NLR of 4 or more (P = 0.01). The 1- and 3- year recurrence-free survival rates in the recipients who had both risk factors were 30.0% and 15.0%, respectively.

CONCLUSION

LDLT should not be performed for patients who have both independent risk factors after any treatments for HCC.

Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse

IMPORTANCE

More than 225 000 surgeries are performed annually in the United States for pelvic organ prolapse (POP). Abdominal sacrocolpopexy is considered the most durable POP surgery, but little is known about safety and long-term effectiveness.

OBJECTIVES

To describe anatomic and symptomatic outcomes up to 7 years after abdominal sacrocolpopexy, and to determine whether these are affected by concomitant anti-incontinence surgery (Burch urethropexy).

DESIGN, SETTING, AND PARTICIPANTS

Long-term follow-up of the randomized, masked 2-year Colpopexy and Urinary Reduction Efforts (CARE) trial of women with stress continence who underwent abdominal sacrocolpopexy between 2002 and 2005 for symptomatic POP and also received either concomitant Burch urethropexy or no urethropexy. Ninety-two percent (215/233) of eligible 2-year CARE trial completers were enrolled in the extended CARE study; and 181 (84%) and 126 (59%) completed 5 and 7 years of follow-up, respectively. The median follow-up was 7 years.

MAIN OUTCOMES AND MEASURES

Symptomatic POP failure requiring retreatment or self-reported bulge; or anatomic POP failure requiring retreatment or Pelvic Organ Prolapse Quantification evaluation demonstrating descent of the vaginal apex below the upper third of the vagina, or anterior or posterior vaginal wall prolapse beyond the hymen. Stress urinary incontinence (SUI) with more than 1 symptom or interval treatment; or overall UI score of 3 or greater on the Incontinence Severity Index.

RESULTS

By year 7, the estimated probabilities of treatment failure (POP, SUI, UI) from parametric survival modeling for the urethropexy group and the no urethropexy group, respectively, were 0.27 and 0.22 for anatomic POP (treatment difference of 0.050; 95% CI, -0.161 to 0.271), 0.29 and 0.24 for symptomatic POP (treatment difference of 0.049; 95% CI, -0.060 to 0.162), 0.48 and 0.34 for composite POP (treatment difference of 0.134; 95% CI, -0.096 to 0.322), 0.62 and 0.77 for SUI (treatment difference of -0.153; 95% CI, -0.268 to 0.030), and 0.75 and 0.81 for overall UI (treatment difference of -0.064; 95% CI, -0.161 to 0.032). Mesh erosion probability at 7 years (estimated by the Kaplan-Meier method) was 10.5% (95% CI, 6.8% to 16.1%).

CONCLUSIONS AND RELEVANCE

During 7 years of follow-up, abdominal sacrocolpopexy failure rates increased in both groups. Urethropexy prevented SUI longer than no urethropexy. Abdominal sacrocolpopexy effectiveness should be balanced with long-term risks of mesh or suture erosion.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00099372.

New paradigms in post-hepatectomy liver failure

INTRODUCTION

Liver failure after hepatectomy remains the most feared postoperative complication. Many risk factors are already known, related to patient's comorbidities, underlying liver disease, received treatments and type of resection. Preoperative assessment of functional liver reserve must be a priority for the surgeon.

METHODS

Physiopathology of post-hepatectomy liver failure is not comparable to fulminant liver failure. Liver regeneration is an early phenomenon whose cellular mechanisms are beginning to be elucidated and allowing most of the time to quickly recover a functional organ. In some cases, microscopic and macroscopic disorganization appears. The hepatocyte hyperproliferation and the asynchronism between hepatocytes and non-hepatocyte cells mitosis probably play a major role in this pathogenesis.

RESULTS

Many peri- or intra-operative techniques try to prevent the occurrence of this potentially lethal complication, but a better understanding of involved mechanisms might help to completely avoid it, or even to extend the possibilities of resection.

CONCLUSION

Future prevention and management may include pharmacological slowing of proliferation, drug or physical modulation of portal flow to reduce shear-stress, stem cells or immortalized hepatocytes injection, and liver bioreactors. Everything must be done to avoid the need for transplantation, which remains today the most efficient treatment of liver failure.

Living-donor liver transplantation and hepatitis C

Hepatitis-C-virus- (HCV-) related end-stage cirrhosis is the primary indication for liver transplantation in many countries. Unfortunately, however, HCV is not eliminated by transplantation and graft reinfection is universal, resulting in fibrosis, cirrhosis, and finally graft decompression. In areas with low deceased-donor organ availability like Japan, living-donor liver transplantation (LDLT) is similarly indicated for HCV cirrhosis as deceased-donor liver transplantation (DDLT) in Western countries and accepted as an established treatment for HCV-cirrhosis, and the results are equivalent to those of DDLT. To prevent graft failure due to recurrent hepatitis C, antiviral treatment with pegylated-interferon and ribavirin is currently considered the most promising regimen with a sustained viral response rate of around 30% to 35%, although the survival benefit of this regimen remains to be investigated. In contrast to DDLT, many Japanese LDLT centers have reported modified treatment regimens as best efforts to secure first graft, such as aggressive preemptive antiviral treatment, escalation of dosages, and elongation of treatment duration.

The causes, risk factors, and outcomes of early relaparotomy after living-donor liver transplantation

BACKGROUND

Although early relaparotomy of the recipient after living-donor liver transplantation (LDLT) is a significant event, its causes, risk factors, and outcomes are still unclear.

METHODS

A retrospective analysis of 284 cases of adult-to-adult LDLT was performed.

RESULTS

The incidence of early relaparotomy of the recipient was 9.2% (n=26). The reasons for relaparotomy were divided into three groups: postoperative bleeding (n=11, 42.3%), insufficient portal venous flow (n=5, 19.2%), and other (n=10, 38.5%). The 6-month graft survival rates of patients in the early laparotomy and nonlaparotomy groups were 61.5% and 88.4%, respectively (P<0.0001). Patients with postoperative bleeding experienced a significantly higher mortality rate (54.6%) than those with other reasons for early relaparotomy (13.3%; P=0.0231). Multivariate analysis showed that a model for end-stage liver disease score of greater than 20 (odds ratio [OR], 9.06; P=0.0434) and an operative blood loss of greater than 15 L (OR, 9.06; P=0.0434) were significant risk factors for graft loss after early relaparotomy. In patients with patent major shunt vessels (>1 cm in diameter, n=31), portal venous flow of less than 1.0 L/min at the end of surgery was a significant risk factor for early relaparotomy to ligate the remaining shunt vessels (OR, 50.5; P=0.0188).

CONCLUSIONS

Early relaparotomy of the recipient is significantly associated with poor graft survival after LDLT. Massive intraoperative blood loss and high model for end-stage liver disease score were associated with poor graft survival in the relaparotomy group.

Prophylaxis against hepatitis B virus recurrence after liver transplantation for hepatitis B virus-related end-stage liver diseases with severe hypersplenism and splenomegaly: role of splenectomy

BACKGROUND

The role of splenectomy on prophylaxis against hepatitis B virus (HBV) recurrence after liver transplantation (LT) for HBV-related end-stage liver diseases with severe hypersplenism and splenomegaly remains unclear today.

METHODS

A total of 510 consecutive patients with HBV-related end-stage liver diseases who underwent LT in Liver Transplantation Center, West China Hospital, Sichuan University (Chengdu, China) between June 1999 and October 2009 were studied retrospectively in this study. Patients were divided into three groups in this study: splenectomized group (group A, n=137), including preoperatively splenectomized subgroup (group A1, n=48) and intraoperatively splenectomized subgroup (group A2, n=89); nonsplenectomized group with severe hypersplenism (group B, n=95); and nonsplenectomized group without severe hypersplenism (group C, n=278). The incidence of posttransplant rejection, posttransplant infection, posttransplant hepatic cell carcinoma recurrence rate, and HBV recurrence rate were recorded. The end of the follow-up period was October 2010.

RESULTS

In this study, six patients with HBV recurrence were found in group A, 15 cases in group B, and 13 cases in group C during the follow-up period. (1) The incidence of posttransplant rejection in patients of group A was significantly lower than that in group B (P=0.0023) and also the HBV recurrence rates in group A markedly decreased (P=0.004). (2) The incidence of posttransplant rejection in group A was significantly lower than that in group C (P=0.0433); however, the incidence of posttransplant infection in group A largely increased compared with that in group C (P=0.0233). The HBV recurrence rates between group A and group C had no significant difference (P=0.804). (3) The HBV recurrence rates in group B were significantly higher than that in group C (P=0.001).

CONCLUSIONS

The results of this study showed that splenectomy could significantly reduce the incidence of posttransplant rejection and HBV recurrence rate for the patients undergoing LT for HBV-related end-stage liver diseases with severe hypersplenism and splenomegaly.

Dual cytoprotective effects of splenectomy for small-for-size liver transplantation in rats

The problems associated with small-for-size liver grafts (ie, high mortality rates, postoperative complications, and acute rejection) remain critical issues in partial orthotopic liver transplantation (OLT). In association with partial OLT, splenectomy (SP) is a procedure used to reduce the portal pressure. However, the precise effects of SP on partial OLT have been unclear. In this study, using small-for-size liver grafts in rats, we examined the cytoprotective effects of SP on OLT. Liver grafts were assigned to 2 groups: a control group (OLT alone) and an SP group (OLT after SP). SP significantly increased animal survival and decreased liver damage. SP exerted the following cytoprotective effects: (1) it improved hepatic microcirculation and prevented increases in the portal pressure after OLT, (2) it suppressed the hepatic infiltration of neutrophils and macrophages through the direct elimination of splenic inflammatory cells before OLT, (3) it decreased the hepatic expression of tumor necrosis factor α and interleukin-6, (4) it attenuated sinusoidal endothelial injury, (5) it decreased plasma endothelin 1 levels and increased hepatic heme oxygenase 1 expression, (6) it suppressed hepatocellular apoptosis through the down-regulation of hepatic caspase-3 and caspase-8 activity, and (7) it increased hepatic regeneration. In conclusion, SP for small-for-size grafts exerts dual cytoprotective effects by preventing excessive portal vein hepatic inflow and eliminating splenic inflammatory cell recruitment into the liver; this in turn inhibits hepatocellular apoptosis and improves liver regeneration.

Impact of simultaneous splenectomy and orthotopic liver transplantation in patients with end-stage liver diseases and splenic hyperfunction

BACKGROUND

Whether splenectomy can be performed simultaneously during liver transplantation in patients with end-stage liver diseases complicated by hypersplenism remains controversial. This study aimed to compare the impact of simultaneous splenectomy on high- and low-risk liver transplant patients with end-stage liver diseases and severe hypersplenism.

METHODS

Forty-two patients with end-stage liver diseases complicated by severe hypersplenism who had undergone orthotopic liver transplantation were enrolled in this study. Splenectomy was performed in 19 of the patients. The 42 patients were grouped according to the risk of liver diseases and operations they received. Patients were considered to be at high-risk if they had at least one of the following conditions: preoperative prothrombin time >5 seconds, portal vein thrombosis, and severe perisplenitis. High-risk patients who had undergone splenectomy were classified into group A, whereas high-risk patients who had not undergone splenectomy were classified into group B. Low-risk patients who had undergone splenectomy were classified into group C, and low-risk patients who had spleen preservation were classified into group D. Operative time, intraoperative blood loss, postoperative bleeding, pulmonary infection, perioperative mortality, and postoperative platelet recovery were analyzed.

RESULTS

Operative time and intraoperative blood loss were greater in group A than in groups B-D (P<0.01), but there was no significant difference between groups C and D (P>0.05). In group A, 3 patients had postoperative bleeding, 5 had pulmonary infection, and 2 had perioperative mortality, which was higher than any other group, but postoperative bleeding, pulmonary infection, and perioperative mortality were similar to those in groups C and D. In patients undergoing simultaneous splenectomy, platelet counts recovered within 6 months after surgery. Thrombocytopenia was sustained in 3 of the 23 patients who did not undergo simultaneous splenectomy.

CONCLUSION

Splenectomy should be avoided during orthotopic liver transplantation in high-risk patients, but this procedure does not increase the operative risk in low-risk patients and may be a valuable method to ensure good postoperative platelet recovery.

Impact of human T cell leukemia virus type 1 in living donor liver transplantation

Human T cell leukemia virus type 1 (HTLV-1) is an endemic retrovirus in southwestern Japan, which causes adult T cell leukemia (ATL) or HTLV-1 associated myelopathy in a minority of carriers. Here, we investigated the impact of HTLV-1 status in living donor liver transplantation (LDLT). Twenty-six of 329 (7.9%) HTLV-1 carriers underwent primary LDLT. One recipient negative for HTLV-1 before LDLT received a graft from an HTLV-1 positive donor. Eight donors were HTLV-1 positive. Twenty-seven recipients (13 male and 14 female; mean age 52.5 years) were reviewed retrospectively. ATL developed in four recipients who ultimately died. The intervals between LDLT and ATL development ranged from 181 to 1315 days. Of the four ATL recipients, two received grafts from HTLV-1 positive donors and two from negative donors. The 1-, 3- and 5-year HTLV-1 carrier survival rates were 91.3%, 78.3% and 66.3%, respectively. Fulminant hepatic failure as a pretransplant diagnosis and a pretransplant MELD score ≥ 15 was identified as risk factors for ATL development in this study (p = 0.001 and p = 0.041, respectively). In conclusion, LDLT can be performed for HTLV-1 positive recipients. However, when fulminant hepatic failure is diagnosed, LDLT should not be performed until further studies have revealed the mechanisms of ATL development.

Risk factors that increase mortality after living donor liver transplantation

BACKGROUND

Female liver to male recipient is a well-accepted risk factor for graft loss in cadaveric liver transplantation. However, gender matching is infeasible because of an insufficient number of available donors. No studies have been performed on the role of gender in the field of living donor liver transplantation. This report investigates the effect of gender mismatch on the outcome of living donor liver transplantation.

METHODS

A total of 335 patients and donors were classified into four groups according to the following gender combinations: male donor to male recipient group (n=104), male donor to female recipient group (n=120), female donor to male recipient (FM) group (n=59), and female donor to female recipient group (n=52). Patient and graft survival were compared among the groups. We performed a multivariable analysis to identify the factors associated with patient mortality.

RESULTS

The 1-, 3-, 5-, and 10-year patient survival rates in the FM group were 80.6%, 66.8%, 61.8%, and 47.7%, respectively. The FM group showed significantly shorter patient survival compared with the other three groups. Independent risk factors for patient mortality were: FM group (P=0.006), pretransplant diabetes mellitus (P=0.001), and a model for end-stage liver disease score more than or equal to 20 (P=0.004).

CONCLUSIONS

Male recipients of transplants from female donors, pretransplant diabetes mellitus, and a model for end-stage liver disease score more than or equal to 20 have poor survival rates.

A critical appraisal of the hemodynamic signal driving liver regeneration

BACKGROUND

Many aspects of the signaling mechanisms involved in the initiation of hepatic regeneration are under current investigation. Nevertheless, the actual mechanisms switching liver regeneration on and off are still unknown. Hemodynamic changes in the liver following partial hepatectomy have been suggested to be a primary stimulus in triggering liver regeneration. Most of the new knowledge about the impact of hemodynamic changes on liver regeneration is both conceptually important and directly relevant to clinical problems.

PURPOSE

The purpose of this review is therefore to exclusively address the hemodynamic signal driving the liver regeneration process.

Kinetics of anti-blood type isoagglutinin titers and B lymphocytes in ABO-incompatible living donor liver transplantation with rituximab and plasma exchange

BACKGROUND

A novel immunosuppression protocol using rituximab and plasma exchange treatment was developed for ABO-incompatible living donor liver transplantation (ABO-I LDLT). The aim of this study was to investigate the kinetics of anti-blood type isoagglutinin titers and the number of blood B lymphocytes in ABO-I LDLT with the new protocol and their impact on the outcomes after ABO-I LDLT.

METHODS

Fifteen patients underwent ABO-I LDLT plus splenectomy with the new protocol between November 2005 and December 2010, and their data were retrospectively analyzed.

RESULTS

CD19-positive lymphocytes in the blood rapidly disappeared after rituximab treatment and began to recover approximately 6 months later. Anti-blood type isoagglutinin titers were lowered by pretransplant plasma exchange (2(3)∼2(12)→2(1)∼2(8)). Although the anti-donor blood type isoagglutinin titers remained consistently low after transplantation in comparison to the pretreatment levels, they persisted long after LDLT, whereas posttransplant biopsy specimens showed sustained A/B antigens on the graft livers. ABO-I hepatitis C virus-positive patients were prone to acceleration of hepatitis C viremia and cytomegalovirus antigenemia in comparison to the control patients.

CONCLUSIONS

Although the new protocol for ABO-I LDLT yielded great success with 100% graft survival, the acceptable anti-blood type isoagglutinin titers just before LDLT, and its application to hepatitis C-positive patients must be determined.

Beneficial effects of supplementation with branched-chain amino acids on postoperative bacteremia in living donor liver transplant recipients

The aim of this study was to investigate the effects of preoperative oral supplementation with branched-chain amino acids (BCAAs) on postoperative bacteremia after living donor liver transplantation (LDLT) for chronic liver failure. Two hundred thirty-six patients who underwent adult-to-adult LDLT were evaluated in this retrospective study. The patients were divided into 2 groups: those who received oral supplementation with BCAAs before transplantation (the BCAA group; n = 129) and those who did not (the non-BCAA group; n = 107). Before the LDLT indication was determined, BCAA supplementation was prescribed by a hepatologist to preserve hepatic reserves. The clinical characteristics and the incidence of bacteremia were compared between the 2 groups. As for clinical characteristics, the Child-Pugh scores (P = 0.0003) and the Model for End-Stage Liver Disease scores (P = 0.0008) were significantly higher in the BCAA group versus the non-BCAA group. The incidence of bacteremia for Child-Pugh class C patients was significantly lower in the BCAA group (6/90 or 6.7%) versus the non-BCAA group (11/50 or 22.0%, P = 0.0132). In a multivariate analysis, non-BCAA supplementation was an independent risk factor for bacteremia. In conclusion, preoperative BCAA supplementation might reduce the incidence of bacteremia after LDLT. Nevertheless, this is a preliminary report, and further studies, such as randomized, prospective studies, are necessary to clarify the beneficial effects of BCAA supplementation on postoperative bacteremia after liver transplantation.

Deconvolution assessment of splenic and splanchnic contributions to portal venous blood flow in liver cirrhosis

PURPOSE

To devise a noninvasive imaging method for resolving the relative contribution of splenic and splanchnic blood flow to portal venous flow and derive quantitative estimates for parameters pertaining to splenic and portal hemodynamics.

METHODS

Tracer concentration-time curves of the aorta, portal vein, and spleen can be extracted from dynamic contrast-enhanced (DCE) CT or MR images. A combination of two tracer analysis approaches, namely arterial-venous sampling and residual tracer deconvolution, is proposed to model these concentration-time curves and derive hemodynamic parameters pertaining to splenic and portal circulation. Clinical feasibility of the proposed method was explored using DCE CT datasets of eight cirrhotic patients. Monte Carlo simulations were performed to evaluate the confidence of the parameter estimates.

RESULTS

Portal blood flow was estimated to be 763.8 +/- 438.1 ml/min in cirrhotic patients and the splenic contribution was found to be elevated (0.75 +/- 0.22). Estimates of splenic blood flow (582 +/- 420 ml/min) and transit time (15.3 +/- 10.1 s) in cirrhotic patients were consistent with reported values obtained using duplex Doppler ultrasound and dynamic scintigraphy, respectively.

CONCLUSIONS

This study shows the feasibility of noninvasive assessment of splenic and portal hemodynamic parameters by DCE imaging using a combination of tracer kinetics modeling techniques.

Splenectomy improves survival by increasing arterial blood supply in a rat model of reduced-size liver

Prevention of acute portal hyperperfusion in small-for-size livers by inflow modulation results in beneficial postoperative outcome. The objective of this study was to unravel the underlying mechanism, emphasizing the intimate relationship between portal venous (PV) and hepatic arterial (HA) blood flow (BF). Rats underwent partial hepatectomy (pHx), splenectomy before pHx or splenectomy and ligation of the A. hepatica before pHx. Portal venous blood flow (PVBF), hepatic arterial blood flow (HABF), and tissue pO₂ were assessed during stepwise resection from 30% to 90%. Hepatic regeneration and hypoxia-responsive gene expression were analyzed in each group after nonlethal 85% pHx. 90% pHx caused a fourfold rise in PVBF, a slight decrease in HABF with a 50% reduction in pO₂, and high mortality. Splenectomy before pHx reduced the PVBF and caused a rise in HABF with doubling in tissue pO₂. An attenuation of hypoxia-responsive gene expression turned into enhanced hepatocellular regeneration and improved survival. A. hepatica ligation abolished the beneficial effect of splenectomy on tissue oxygenation, proliferation, and outcome. In conclusion, the beneficial effect of splenectomy in small-for-size livers can be attributed to a rise in HABF with sufficient oxygen supply rather than to a reduced portal venous hyperperfusion to the remnant liver.

Variants in IL28B in liver recipients and donors correlate with response to peg-interferon and ribavirin therapy for recurrent hepatitis C

BACKGROUND & AIMS

Patients with hepatitis C virus (HCV)-related liver disease frequently undergo orthotopic liver transplantation, but recurrent hepatitis C is still a major cause of morbidity. Patients are treated with peg-interferon and ribavirin (PEG-IFN/RBV), which has substantial side effects and is costly. We investigated genetic factors of host, liver donor, and virus that might predict sensitivity of patients with recurrent hepatitis C to PEG-IFN/RBV.

METHODS

Liver samples were analyzed from 67 HCV-infected recipients and 41 liver donors. Liver recipient and donor DNA samples were screened for single nucleotide polymorphisms near the IL28B genes (rs12980275 and rs8099917) that affect sensitivity to PEG-IFN/RBV. HCV RNA was isolated from patients and analyzed for mutations in the core, the IFN sensitivity-determining region, and IFN/RBV resistance-determining regions in nonstructural protein 5A.

RESULTS

In liver recipients and donors, the IL28B single nucleotide polymorphism rs8099917 was significantly associated with a sustained viral response (SVR; P = 0.003 and P = .025, respectively). Intrahepatic expression of IL28 messenger RNA was significantly lower in recipients and donors that carried the minor alleles (T/G or T/T) in rs8099917 (P = .010 and .009, respectively). Genetic analyses of IL28B in patients and donors and of the core and nonstructural protein 5A regions encoded by HCV RNA predicted an SVR with 83% sensitivity and 82% specificity; this was more effective than analysis of any single genetic feature.

CONCLUSIONS

In patients with recurrent HCV infection after orthotopic liver transplantation, combination analyses of single nucleotide polymorphisms of IL28B in recipient and donor tissues and mutations in HCV RNA allow prediction of SVR to PEG-IFN/RBV therapy.

Risk factors for portal venous thrombosis after splenectomy in patients with cirrhosis and portal hypertension (Br J Surg 2010; 97: 910-916)

Background

Portal venous thrombosis (PVT) is a potentially fatal complication following splenectomy. Its mechanisms and risk factors are poorly understood, especially in patients with cirrhosis and portal hypertension. This study investigated risk factors for PVT following splenectomy in such patients.

Methods

All consecutive patients with cirrhosis who underwent splenectomy in Kyushu University Hospital between 1998 and 2004 were included in this retrospective study. They were divided into two groups based on the presence or absence of postoperative PVT. Preoperative and operative factors were compared, and the relationships between formation of PVT and its independent variables were analysed. In some cases, portal venous flow was measured before and after splenectomy using duplex Doppler ultrasonography.

Results

PVT developed after surgery in 17 (24 per cent) of 70 patients studied. Multivariable analysis showed that increased splenic vein diameter and low white cell count were significant independent risk factors for PVT. Portal venous flow after splenectomy was greatly reduced in the PVT group, but not in patients without PVT.

Conclusion

Large splenic vein diameter and low white cell count are independent risk factors for PVT after splenectomy in patients with cirrhosis and portal hypertension.