[A Case of 11-Year Patient Survival after the Resection of a Metastatic Pancreatic Tumor of Sigmoid Colon Cancer].

A 44-year-old woman underwent a sigmoidectomy for sigmoid colon cancer in March 2002. At 5 years after the primary surgery, she underwent 2 hepatectomies, 2 anastomotic resections, 1 lung resection, and 1 radiofrequency ablation. Computed tomography revealed a mass in the pancreatic tail in January 2008. We performed distal pancreatectomy. The specimen showed metastases ofthe sigmoid colon cancer. Computed tomography revealed metastases to the left iliac lymph node in September 2010. She underwent chemotherapy with IRIS for the lymph node metastases. After 16 chemotherapy sessions, the lymph node metastases disappeared. The patient is alive 11 years after the pancreatectomy. Resectable pancreatic metastasis from colorectal cancer is rare. Multimodal treatment that includes radical surgery may achieve long-term survival in some cases.

[A Case of Long-Term Survival after Repeated Peritoneal Recurrences of Perforated Sigmoid Colon Cancer Treated with Systemic Chemotherapy and R0 Resection of Peritoneal Tumors].

We report here a case of long-term survival with repeated peritoneal recurrences after resection of perforated sigmoid colon cancer. A 65-year-old man presented with diarrhea and abdominal pain. Computed tomography(CT)revealed diffuse peritonitis caused by perforated sigmoid colon cancer. We performed sigmoidectomy with D2 lymphadenectomy and descending colostomy. Postoperatively, S-1 was administered for 12 months as adjuvant chemotherapy. CT showed peritoneal nodules 56 months after the surgery. After 10 courses of mFOLFOX6 plus bevacizumab, the tumors decreased in size (reduction rate of 34.4%; a partial response). Subsequently, 3 peritoneal nodules were resected with curative intent. Another peritoneal nodule was detected 57 months after the second surgery. After 3 courses of XELOX plus bevacizumab, the nodule decreased in size(reduction rate of 69.0%; a partial response). The nodule was resected with a curative intent. At the last follow-up 135 months after the first surgery, the patient remains alive with no evidence of disease.

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

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

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

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

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

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

Splenic-intrahepatic left portal shunt in an adult patient with extrahepatic portal vein obstruction without recurrence after pancreaticoduodenectomy.

In the last decade, a superior mesenteric-intrahepatic left portal shunt (Rex shunt) has been reported for successful management of extrahepatic portal vein obstruction in children. However, in adults, a mesocaval shunt has been generally performed for the surgical management of extrahepatic portal vein obstruction because of the complexity of the underlying disease and the difficulty of the superior mesenteric-intrahepatic left portal shunt. We herein report an adult patient who was successfully treated by splenic-intrahepatic left portal shunt with an artificial graft (6-mm polytetrafluoroethylene) for complete obstruction of the extrahepatic portal vein following pancreaticoduodenectomy. The shunt procedure not only relieved portal hypertension but also restored hepatic portal flow. In the near future, the Rex shunt should be considered for a beneficial management of extrahepatic portal vein obstruction, even in adults.

Risk factors and prevention of biliary anastomotic complications in adult living donor liver transplantation.

AIM: To evaluate risk factors of biliary anastomotic complications (BACs) and outcomes according to type of biliary reconstruction. METHODS: A total of 33 consecutive adult living donor liver transplantation (LDLT) were reviewed, 17 of which had undergone Duct-to-Duct anastomosis (D-D). The remaining 16 patients received Roux-en-Y anastomosis (R-Y). The perioperative factors, such as the type of graft and the number of graft bile ducts, were analyzed retrospectively. RESULTS: The overall incidence of BACs was 39.4%. The incidence of BACs was significantly higher in the patients with than without neoadjuvant chemotherapy (71.4% vs 10%, P = 0.050). There was no significant difference in the incidence of biliary leakage in patients with D-D vs those with R-Y. The incidence of biliary strictures following the healing of biliary leakage was significantly higher in D-D (60%) than in R-Y (0%) (P = 0.026). However, the incidence of BACs related bacteremia was significantly higher in R-Y than in D-D (71.4% vs 0%, P = 0.008). In D-D, use of T-tube stent remarkably reduced the incidence of BACs, compared with straight tube stent (0% vs 50%, P = 0.049). CONCLUSION: Our experience showed an increase of BACs related bacteremia in the patients with R-Y. Therefore, D-D might be a preferred biliary reconstruction. However, the surgical refinement of D-D should be required because of the high incidence of biliary strictures. Use of the T-tube stent might lead to a significant reduction of BACs in D-D.

Characteristics of biliary reconstruction, using a T-tube, as compared to those with other methods, in left-lobe adult living-donor liver transplantation.

BACKGROUND/PURPOSE: Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living-donor liver transplantation. The aim of this study was to analyze the clinical implications of three different methods of biliary reconstruction in left-lobe adult living-donor liver transplantation. METHODS: We retrospectively compared three groups of patients: those who had Roux-en-Y hepaticojejunostomy (HJ; n = 11) biliary reconstruction, those who had duct-to-duct hepaticohepaticostomy (HH) with external stent (n = 11), and those who had HH with a T-tube (n = 6). Median follow-up for each group was 31, 30, and 10 months, respectively. RESULTS: Bile leaks were observed in 45.5% of the patients in both the HJ group and the HH with external stent group. Biliary anastomotic strictures occurred in 9% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with external stent. No biliary complications were observed in the HH with a T-tube group (P = 0.049). CONCLUSIONS: Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up period, these encouraging preliminary results may warrant further studies of this biliary reconstruction technique in left-lobe adult living-donor liver transplantation.

FK506 may reduce early liver injury following living related liver transplantation.

BACKGROUND/AIMS: We investigated the influence of FK506 which has been used frequently after transplant surgery as an immunosuppressant, on liver injury after partial hepatectomy by comparing laboratory data from donors and recipients after liver transplantation. METHODOLOGY: Seventeen donors and respective recipients who underwent living related donor liver transplantation were included in the present study. Serum levels of transaminases and cytokines were measured and compared preoperatively and in the early period after the operation. RESULTS: Serum level of asparaginic acid aminotransferase in the postoperative day 1 was significantly higher in the donor group. Serum levels of alanine aminotransferase in the early period after the operation were significantly higher in the donor group. Serum levels of interferon y and soluble Fas ligand in the early period after the operation were significantly higher in the donor group. Steroid doses administered were significantly higher in the recipient group. CONCLUSIONS: FK506 administration and steroid administration in larger doses were thought to reduce serum transaminase levels of the recipient group. These findings might suggest that cell-mediated immunity weigh heavier than the operation time of ischemia-reperfusion injury as a cause of liver injury after partial hepatectomy.

Video-assisted living donor hemihepatectomy through a 12-cm incision for adult-to-adult liver transplantation.

OBJECTIVES: There has been remarkable progress in recent technical innovations for laparoscopic hepatectomy. However, a laparoscopic procedure rarely has been indicated for donation of the liver in living-related liver transplantation (LRLT). Here, we described the technique and the outcome of video-assisted donor hepatectomy (VADH) for adult-to-adult LRLT. METHODS: For 13 donors in adult-to-adult LRLT, 3 types of major hepatectomy--right hemihepatectomy (3), and left hemihepatectomy, with or without the caudate lobe (10)--were performed through video-assisted procedures; surgical manipulation via ports or via a 12-cm incision and viewing through a laparoscope or through incision were combined and used. RESULTS: VADH was completed in 13 donors, with a median operation time of 363 +/- 33 minutes and a median blood loss of 302 +/- 191 mL. No complications specific to video-assisted procedures, postoperative bile leak, or bleeding were observed. The restoration of the liver function was smooth, and the use of an analgesic (median: 1.2 times) was reduced, compared with the historical control (median: 3.8 times) that underwent a standard donation of the liver. Currently, all donors are healthy and have returned to their previous activities. The grafts have been functioning well, excluding 3 recipients who succumbed to serious complications unrelated to the video-assisted procedure. CONCLUSION: We have shown a new method of VADH through a 12-cm laparotomy for adult-to-adult LRLT. This technique is as feasible as standard open donor hepatectomy, with less pain and with improved postoperative symptoms.

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

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

Preoperative human-telomerase reverse transcriptase mRNA in peripheral blood and tumor recurrence in living-related liver transplantation for hepatocellular carcinoma.

BACKGROUND/AIMS: In this study we evaluated the potential role of preoperative h-TERT mRNA expression in peripheral blood as a tool for predicting prognosis and tumor recurrence after living-related liver donor transplantation (LRLDT). METHODOLOGY: The study included patients with unresectable HCC who underwent LRLDT from July 1999 to May 2003. RESULTS: There was no significant difference between the survival curves of those patients who met the Milan criteria and those who did not. However, there was a statistically significant difference (p=0.032) between the survival curves of those patients with positive preoperative h-TERT mRNA expression, and those who either had an initially negative preoperative h-TERT mRNA or who converted from positive to negative after neoadjuvant immunochemotherapy. CONCLUSIONS: In conclusion, the presence or absence of h-TERT mRNA in the peripheral blood may be a useful criterion in evaluating HCC patients for transplantation, as well as a valuable method of assessing anti-tumor therapy and tumor relapse.

Successful surgical treatment for hepatocellular carcinoma and concomitant risky esophageal varices.

BACKGROUND/AIMS: In our frequent encounters with liver cirrhotic patients with hepatocellular carcinoma (HCC) and concomitant risky esophageal varices, we have found that some of them required endoscopic injection sclerotherapy (EIS) and/or surgical treatment for esophageal variceal bleeding due to increased portal venous pressure after aggressive hepatectomy. In this study, we investigated the short-term effect of aggressive hepatectomy accompanied with left gastric venous caval shunt (Inokuchi's shunt) for esophageal varices and postoperative liver function. METHODOLOGY: Four cirrhotic patients with HCC and concomitant risky esophageal varices underwent hepatectomy with Inokuchi's shunt from 1999 to 2001. The mean age was 58.0 +/- 15.3 years old and all patients were classified in Child grade A or B. We investigated hematochemical data and endoscopic findings before and after surgery. RESULTS: One of the patients experienced disappearance of esophageal varices at discharge. In the others, postoperative endoscopy showed disappearance of CRS and reduced sizes of varices. In one patient, hepatic encephalopathy appeared transiently with bleeding from a duodenal ulcer at one month after surgery. However, the patient improved by conservative treatment. Three of the patients have survived well without recurrence of HCC and esophageal variceal bleeding; the remaining patient died from a recurrence of HCC. CONCLUSIONS: Inokuchi's shunt may be sufficiently effective to treat risky esophageal varices associated with resectable HCC and may be safe even if it is undertaken along with a major hepatectomy.

Augmentation of heme oxygenase-1 expression in the graft immediately after implantation in adult living-donor liver transplantation.

Heme oxygenase (HO)-1 is a cytoprotective protein and has recently been identified as a graft survival gene. However, there are little data currently available regarding the expression of HO-1 in human living-related liver transplantation. This is the first report that HO-1 expression is increased in small-for-size liver allografts. We performed biopsies of the graft liver and donor liver left in six patients at four time points during the procedure and studied HO-1 expression by reverse-transcriptase polymerase chain reaction and immunohistochemistry. HO-1 mRNA was expressed at a low level in steady-state liver tissue but was strongly expressed after perfusion of the graft liver. HO-1 expression increased in nonparenchymal cells in the human graft liver. The number of HO-1 positive cells increased threefold by the end of liver transplantation. This study suggests that ischemia-reperfusion injury and excessive shear stress secondary to portal hypertension might augment HO-1 expression in the graft liver.

Wall shear stress and intrahepatic leukocytes of graft in living related donor liver transplantation.

BACKGROUND/AIMS: We investigated the influence of HTK solution against natural killer T cells and thymic T cells in liver graft before and after perfusion in adult living related donor liver transplantation. METHODOLOGY: Graft samples were obtained before liver resection, after perfusion, and one hour after liver transplantation. Flowcytometry analysis was conducted using several human natural killer markers; CD16, CD56, CD57, and CD161. RESULTS: Natural killer T cells existed prominently in the liver leukocytes compared with their presence in peripheral blood lymphocytes, and the difference was significant. CD56+ T and CD161+ T cells, in comparison with CD16+ T cells and CD57+ T cells, were especially numerous in the liver. The proportion of CD56+ T and CD161+ T cells increased in the graft immediately after perfusion with HTK solution. However, CD16+ T cells and CD57+ T cells decreased in the graft immediately after perfusion and reperfusion of portal blood flow. Thymus-derived cells also decreased significantly after perfusion. The proportion of CD56+ T cells among CD3+ cells showed a significant increase immediately after perfusion. All types of natural killer cells in the graft immediately increased after perfusion by HTK solution and reperfusion of portal blood flow. Compared with CD57+ NKT cells, CD56+ NKT cells showed a significant tendency to stay in the liver graft against the perfusion. CD57+ NKT cells tended to wash out from the liver into the systemic circulation. Moreover, thymus-derived T cells showed the strongest tendency to wash out from the liver graft. CONCLUSIONS: CD56+ NKT cells and natural killer cells are more involved in local immunity, whereas thymus-derived cells and CD57+ NKT cells are involved in regulation of systemic immunity. Alloimmunity between local and systemic systems may be affected by the dynamic changes in hepatic circulation associated with living related donor liver transplantation.

Carbon monoxide hemoglobin and bilirubin metabolism in adult living-related liver transplantation.

BACKGROUND/AIMS: Hemeoxygenase-1 produces carbon monoxide as a byproduct of hemoglobin metabolism. The present study examines the relationship between carbon monoxide production and hyperbilirubinemia following adult living-related liver transplantation with special attention to the contribution of shear stress in retarding regeneration. METHODOLOGY: Case records from 16 patients who underwent adult living-related liver transplantation from March 1999 to May 2001 were reviewed. Patients were divided into group A (graft weight: recipient body weight ratio > or = 1) and group B (graft weight: recipient body weight ratio < 1). Clinical characteristics and outcome in the two groups were compared. RESULTS: Total serum bilirubin concentration and the direct: total serum bilirubin concentration were higher in group B than group A (p < 0.01). Further, the carbon monoxide-hemoglobin concentration correlated with the total serum bilirubin concentration (r = 0.81, p < 0.0001) and also was higher in group B than group A (p < 0.05). The arterial: ketone body ratio rose similarly during the first week in both groups. CONCLUSIONS: Persistent hyperbilirubinemia in small-for-size grafts and concomitant carbon monoxide-hemoglobinemia reflect both parenchymal and Kupffer cell dysfunction. The role of shear stress in the portal system and its relationship to portal hypertension are discussed.

Expression of heme oxygenase-1 in rat ontogeny.

Heme oxygenase (HO), the heme-degrading enzyme, plays an important role in heme catabolism. Among three isozymes, HO-1 is an inducible form expressed mainly in macrophages. In rat ontogeny, HO-1 immunoreactivity was detected in mononuclear cells in the yolk sac at 10 days of gestation. HO-1-expressing cells were then detected in the fetal liver and their numbers increased during the gestational period. The numbers of HO-1-positive cells and HO-1 mRNA levels in the liver peaked at 18 days of gestation. Most of the macrophages expressed both HO-1 and a macrophage scavenger receptor. Macrophages in the fetal liver showed marked hemophagocytosis. Macrophages in the lung, spleen, bone marrow, and other tissues also expressed HO-1. HO-1 immunoreactivity was also observed in syncytial cells of the chorionic villi, the endodermal layer of the yolk sac, and renal tubules of the fetus. Intestinal mucosal epithelial cells expressed HO-1 after birth. These findings imply that HO-1 is crucial for macrophages in heme catabolism from an early stage of ontogeny. HO-1 expression in non-macrophagic cells may be required for other purposes such as protection from oxidative stress and various stimuli.

Repeating intraportal donor-specific transfusion may induce tolerance following adult living-related donor liver transplantation.

BACKGROUND/AIMS: Oral or portal administration of allogeneic antigens downregulates the alloimmune response and prolongs graft survival following organ transplantation. However, the effect of donor-specific transfusion via the portal vein has been reported in rodent models, but has not been reported in human cases. We investigated whether donor-specific transfusion via the portal vein would bring up the clinical and immunological benefits in living-related donor liver transplantation. METHODOLOGY: Eighteen patients who underwent living-related donor liver transplantation from March 1999 to December 2001, were investigated. Seven patients were given the Tac + steroid regimen (IP(-) group: n = 7, mean age 54 +/- 9 yo). Eleven patients had postoperative repeated donor specific transfusion performed via a portal venous catheter inserted from vena colica media besides from the Tac + steroid (IP(+) group: n = 11, mean age 45 +/- 15 yo). The clinical effects of the reduction of immunosuppression and the rejection, and the immunological analysis were studied in the two groups. RESULTS: Total amount of methylprednisolone and prednisolone within one month in the IP(+) group was smaller than that in the IP(-) group with statistical significance. Amount of Tac within one month and Trough level of Tac was statistically smaller in the IP(+) group than that in the IP(-) group. Minimum dose of Tac in the IP(+) group was clearly smaller than that in the IP(-) group with statistical significance. The frequency of acute cellular rejection within one month and after one month or total frequency of acute cellular rejection in the IP(+) group tended to be less than that in the IP(-) group. Macrochimerism of donor type CD56+ T cells in a graft were confirmed in patients with donor-specific transfusion via the portal vein. Conversely recipient type CD56+ T cells increased in the graft liver in patients without donor-specific transfusion. IL-10 production of the donor-specific transfusion(+) group was higher than that of the donor-specific transfusion(-) group on day 1 after living-related donor liver transplantation. CONCLUSIONS: The repeated donor-specific transfusion via the portal vein has brought the rapid reduction of immunosuppressants. Donor type natural killer T cells especially CD56+ T cells, may induce tolerance by Veto mechanism and anti-idiotype network mechanism. These benefits might introduce more advantages in frequency of complications and cost of transplantation.

Thrombopoietin levels and peripheral platelet counts following living related donor liver transplantation.

BACKGROUND/AIMS: Thrombopoietin is the primary hematopoietic growth factor. Thrombopoietin deficiency may cause thrombocytopenia in advanced liver disease. The aim of our study was to investigate the relevance of thrombopoietin levels to peripheral platelet counts in patients with liver disease who underwent LRDLT (living related donor liver transplantation). METHODOLOGY: We divided the six patients who underwent LRDLT into two groups. Group 1 had thrombocytopenia and group 2 had normal platelet counts. We measured serum thrombopoietin and peripheral platelet counts before and after LRDLT. RESULTS: Pre-LRDLT thrombopoietin and peripheral platelet counts were lower in group 1 than in group 2. Thrombopoietin in group 1 significantly increased on the first day after LRDLT and peripheral platelet counts in group 1 increased following the rise in thrombopoietin (p < 0.05). Moreover, a marked increase in thrombopoietin and peripheral platelet counts was found in splenectomized patients during LRDLT. CONCLUSIONS: These findings suggested inadequate thrombopoietin production in advanced stage liver disease which caused thrombocytopenia. Improvement of thrombopoietin production in graft liver function may contribute to increase of peripheral platelet counts.