Magnetic compression anastomosis for bile duct stenosis after donor left hepatectomy: a case report.

Magnetic compression anastomosis (MCA) provides a minimally invasive treatment creating a nonsurgical, sutureless enteric anastomosis in conjunction with an interventional radiologic technique by using 2 high-power magnets. Recently, the MCA technique has been applied to bile duct strictures after living donor liver transplantation or major hepatectomy. Herein we described use of MCA for bile duct stenosis 5 months after donor left hepatectomy in a 24-year-old man who presented with a stricture at the porta hepatis and intrahepatic bile duct dilatation. Unsuccessful transpapillary biliary drainage and balloon dilatation through a percutaneous transhepatic biliary drainage (PTBD) route led to the MCA. A 4-mm-diameter cylindrical samarium-cobalt (Sm-Co) daughter magnet with a long nylon wire was placed at the superior site of the obstruction through the PTBD route. A 5-mm-diameter Sm-Co parent magnet with an attached nylon handle was endoscopically inserted into the common bile duct and placed at the inferior site of obstruction. The 2 magnets were attracted, sandwiching the stricture and establishing a reanastomosis. In conclusion, the MCA technique was a unique procedure for choledochocholedochostomy in a patient with bile duct stenosis after donor hepatectomy.

Successful laparoscopic-assisted hemostasis of intrathoracic massive vericeal rupture during living related liver transplantation: a case report.

End-stage liver disease that requires transplantation is usually accompained by esophagogastric or another collateral vessel varices. Sometimes, the esophagogastric varices rupture intraoperatively during liver transplantation. However we have reported rare case of rupture of an intercostal varicose vein, which was controlled successfully by flexible laparoscopy. The patient was a 62-year-old man, who suffered decompensated liver cirrhosis with hepatocellular carcinoma. The Child-Pugh score was 11 and the Model for End-stage Liver Diseases score was 14. Preoperative gastrointestinal fiberscopy and colon fiberscopy examinations revealed esophagogastric and rectal varices. He underwent living related liver transplantation from his son on February 10, 2010. Just after the liver transplantation, the patient's blood pressure tended to decrease. Chest radiography demonstrated a massive right pleural effusion. We drained 3000 mL of blood by thoracic puncture. Therefore we reoperated him for the question an intrathoracic variceal hemorrhage. We confirmed variceal bleeding after removal of the massive hematoma by opening the diaphragm. However, we could neigher show directly the bleeding point in the anterior thorax nor stop it because of the constriction of the diaphragm. Therefore we used a flexible laparoscope to both confirm the bleeding point and to achieve hemostasis. We believe that theoperative compression of the intercostal varicose vein by a retractor induced the vascular rupture.

Regulatory T-cell activation among patients who displayed operational tolerance following intra-portal administration of donor-specific antigens in living donor liver transplantation.

Immunologic tolerance is the goal for all transplant surgeons. We have reported that repeated donor-specific antigen transfusion (DST) via the portal vein allowed rapid reduction of immunosuppressants with decreased acute cellular rejection episodes among living donor liver transplantations (LDLT). Moreover, we demonstrated that intraportal DST induced macrochimerism of donor type CD56+ T cells in the liver graft. We examined the impact of FoxP3+CD4+CD25+ T cells in recipients who acquired almost tolerance after LDLT with intraportal DST. We defined the amount of immunosuppressants administered less than one time per week as "almost tolerance" after LDLT, which occurred among 14% of DST patients after adult-to-adult LDLT. Two patients (4%) have gotten been we used from immunosuppressants more than 2 years after LDLT 4 years prior. We examined the impact of FoxP3+CD4+CD25+ T cells both in recipients with almost daily immunosuppressants and those who acquired almost tolerance. The proportion of FoxP3+/CD4+CD25+ T cells in the almost tolerance group was significantly higher than that in the almost daily immunosuppressant group (P<.05). The increased proportion of FoxP3+/CD4+CD25+ T cells significantly correlated with time after LRLT (y=0.0964x+42.02, R2=0.8854). Repeated intraportal DST may be a goot tool to induce immunologic tolerance after LDLT. Both donor type CD56+ T cells and FoxP3+/CD4+CD25+ T cells may act as important regulatory cells for tolerance. The period after LDLT is important for acquiring immunologic tolerance.

Liver transplantation surgical techniques for extensive retroperitoneal tumor with major blood vessel involvement: a case report.

A case of a 71-year-old man with a huge retroperitoneal tumor situated behind the liver, which strongly compressed the liver inferior vena cava (IVC), and gastrointestinal tract is described. With the techniques of whole liver extraction and autologous orthotopic liver transplantation, we successfully removed the tumor. We have the surgical techniques, essential elements, and indications for this procedure.

Isolated dissection of the superior mesenteric artery after living donor liver transplantation: a case report.

Isolated dissection of the superior mesenteric artery (SMA) not associated with aortic dissection is rare, particularly after living donor liver transplantation (LDLT). We experienced a case of isolated dissection of the SMA after LDLT performed in a 56-year-old man diagnosed with hepatitis B virus-related cirrhosis and hepatocellular carcinoma within the Milan criteria. He had no past history of hypertension or diabetes mellitus. At 6 days after LDLT, the patient underwent an emergency portal vein thrombectomy with ligation of a huge left gastric vein shunt. Thereafter anticoagulant and antiplatelet therapy were initiated. At 12 days after LDLT, a contrast-enhanced computer assisted tomography (CT) scan revealed the presence of a thrombus in a false lumen and a thin flap enlarged in the SMA. Because he presented neither abdominal pain nor biochemical data suggesting mesenteric ischemia, he was treated with antihypertensive agents in addition to anticoagulant and antiplatelet therapy. The thrombus in the false lumen was reduced and the intimal flap in the SMA disappeared according to the results of a CT scan 4 months after LDLT. He has remained free of symptoms for 4 years. The strategy to treat isolated SMA dissection is not well established. Urgent surgery is indicated for acute symptomatic forms with a suspicion of mesenteric ischemia; conservative treatment is indicated for patients with minimal, resolving, or no pain, but requires close follow-up.

The inferior mesenteric vein to the left gonadal vein shunt for gastroesophageal varices and extrahepatic portal vein thrombosis after living donor liver transplantation: a case report.

This 59-year-old woman underwent living donor liver transplantation using a left lobe graft as an aid for autoimmune hepatitis in 2003. Splenectomy was also performed because of blood type incompatibility. Follow-up endoscopic and computed tomography examinations showed gastroesophageal varices with extra hepatic portal vein thrombosis in 2007 that increased (esophageal varices [EV]: locus superior [Ls], moderately enlarged, beady varices [F2], Blue varices [Cb], presence of small in number and localized red color sign [RC1] and telangiectasia [TE+], gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderately enlarged, beady varices [F2], white varices [Cw], absence of red color sign [RC-]). Portal venous flow to the gastroesophageal varices was also confirmed from a large right gastric vein. The splenic vein was thrombosed. Blood flow to the liver graft was totally supplied from the hepatic artery. The graft was functioning well. Because these gastroesophageal varices had a high risk of variceal bleeding, we decided to proceed with a portal reconstruction of a surgical portosystemic shunt in 2008. Severe adhesions were observed around the portal vein. It was impossible to perform portal reconstruction. There were relatively fewes adhesious in the left lower side of the abdominal cavity. We decided to create an inferior mesenteric vein to left gonadal vein shunt. The portal vein pressure decreased from 31.0 to 21.5 cm H2O thereafter. The postoperative course was smooth without any complication. This patient was discharged on the postoperative day 15. Follow-up endoscopic study showed the improvement in the gastroesophageal varices (EV: Ls, F2, Cb, RC(-), GV: Lg-c, F2, Cw, RC-) at 3 months after the operation. We also comfirmed the patency of the shunt by serial computed tomography examinations.

Auxiliary partial orthotopic living donor liver transplantation for fulminant hepatic failure with flat electroencephalogram: a case report.

A 54-year-old woman with hepatic encephalopathy grade IV (coma) and flat electroencephalogram (EEG) due to fulminant liver failure (FHF) due to hepatitis B virus infection was admitted to our hospital on May 24, 2002. We performed a living donor auxiliary partial orthotopic liver transplantation (APOLT) emergently on the day of admission. The donor was the patient's son, whose ABO blood group was identical. The immunosuppressant regimen consisted of tacrolimus and low-dose steroids. The left lobe (260 g) of the recipient, which was removed using a Pringle maneuver, was reconstructed with a left lobe (417 g) graft from the donor, which was orthotopically positioned as an auxiliary support. The patient remained in a coma for the first 5 days but on day 6 her eyes opened and followed objects. Finally, she recovered an almost normal appearance. Abdominal compartment syndrome, bile leak, and a mild rejection episode occurred during the postoperative course; all were treated successfully. The patient was discharged on the postoperative day 142. Computed tomography (CT) scan and biopsy were used to follow the changes in the graft and the native liver. On postoperative day 520, a CT scan showed a remarkable improvement in native liver size (493 cm3). Immunosuppression was tapered off and stopped on the postoperative day 635 to surrender the grafted liver. The graft liver biopsy specimen showed severe chronic rejection. The present status of the patient, who is now more than 7 years after transplantation, is an absence of neurological findings with normal liver function.

The new method of time-lag ligation for portosystemic shunt using coronary artery bypass graft occluder for adult living donor liver transplantation.

We performed a living donor liver transplantation (LDLT) for a 57-year-old man who had end-stage liver failure with portal hypertension and an inferior mesenteric vein-left testicular vein (IMV-LTV) shunt. At operation, we did not clamp the shunt but encircled it with a coronary artery bypass graft (CABG) occluder (Sumitomo Bakelite K.K., Japan), which was passed outside the body through the abdominal wall to time-lag ligation (TLL). On postoperative day (POD) 5, we observed decreased portal flow. We performed TLL of the shunt using the CABG occluder without re-laparotomy. The portal flow increased, while the portal vein pressure increased slightly. In LDLT, portosystemic shunt has been reported to be a cause of portal thrombus formation or graft liver atrophy due to decreased PV flow in the mid postoperative period. However, perioperative ligation of a portosystemic shunt may prevent regeneration of the grafted liver because of excessive portal hypertension. Therefore the technique of time-lag ligation of a portosystemic shunt using a CABG occluder may be a minimally invasive, useful method to achieve physiological liver graft regeneration.

Impact of intraportal donor-specific leukocyte transfusion for adult ABO-incompatible liver transplantation.

INTRODUCTION: We have reported that repeated donor-specific leukocyte transfusions (DSLT) via the portal vein allow rapid reduction of immunosuppressants and decrease the occurrence of acute cellular rejection. Herein, we examined the immunological benefits of DSLT in adult ABO-incompatible living donor liver transplantation (LDLT). MATERIALS AND METHODS: Ten adult patients (MELD score, 19.4 +/- 7.3; range, 12-29) underwent LDLT from ABO-incompatible donors from August 2003 to November 2007. The antirejection therapy included multiple perioperative plasmaphereses, splenectomy, and quadruple immunosuppression. In addition to these conventional approaches, we performed 4 intraportal administrations of DSLT after transplantation. RESULTS: There was no humoral rejection in any patient. Two patients experienced mild cellular rejection requiring steroid pulse therapy. Both donor-specific immunoglobulin (Ig)M and IgG A/B antibodies in all patients decreased following transplantation by 16 fold. By flow cytometry, donor type of CD56+NK T cells existed in the liver graft showing macrochimerism at 1 month after liver transplantation. Furthermore, interleukin (IL)-10 production of Th2 type cytokines was up-regulated after transplantation. Three patients died of sepsis and infection. The 5-year survival rate was 70% by the Kaplan-Meier method. CONCLUSION: Adult ABO-incompatible liver transplantation can be performed with acceptable patient and graft survival rates with a low risk of antibody-mediated rejection using intraportal administration of DSLT. Donor type CD56+NK T cells may induce tolerance by a veto or an anti-idiotype network mechanism.

Feasibility of auxiliary partial living donor liver transplantation for fulminant hepatic failure as an aid for small-for-size graft: single center experience.

Auxiliary partial orthotopic liver transplantation (APOLT) or heterotopic auxiliary partial liver transplantation (HAPLT) was initially indicated for potentially reversible fulminant hepatic failure (FHF). We started auxiliary partial living donor liver transplantation (LDLT) for FHF in February 2002. Since then, 5 FHF patients (3 females and 2 males) underwent auxiliary partial LDLT: 3 cases of APOLT and 2 cases of HAPLT. All of them received a small-for-size graft: graft-to-recipient weight ratio (GRWR) < or = 1.0%. The etiologies of FHF were hepatitis B virus (HBV) in 1, Wilson's disease in 1, and unknown origin in 3 cases. Three were the acute type and 2 the subacute type of FHF. Median age was 45 years (range, 14-54 years). Blood type was identical in all cases. A left lobe graft was used in 4 instances and a right lobe graft in 1 case. Median GRWR was 0.74 (range, 0.42-0.85). Median follow-up was 42 months (range, 3 days to 70 months). Three of 5 patients (60%) were alive (at 42, 67, and 70 months) and 1 was free of immunosuppression after sufficient recovery of the native liver. Two cases succumbed: 1 at postoperative day 3 because of cytomegalovirus pneumonia and 1 at 10 months after APOLT because of sepsis. Complications were seen in all 5 patients: Relaparotomy for hemostasis in 3, decompression surgery of the abdominal cavity in 1, rehepaticojejunostomy in 1, and biliary strictures in 2 cases. Auxiliary partial LDLT may be a choice as an aid for a small-for-size graft in FHF.

Long-term follow-up study of biliary reconstructions and complications after adult living donor liver transplantation: feasibility of duct-to-duct reconstruction with a T-tube stent.

The aim of this study was to analyze the feasibility of duct-to-duct biliary reconstruction (hepaticohepaticostomy) with a T-tube stent (HH-T) after adult living donor liver transplantation (LDLT) based on long-term follow-up. We retrospectively evaluated 63 primary adult LDLTs who had survived >1 month from March 1999 to January 2008. We compared the incidence of bile leaks and biliary strictures (BS) in 3 groups of patients: Roux-en-Y hepaticojejunostomy (HJ; n = 18); duct-to-duct hepaticohepaticostomy with external stents except a T-tube (HH; n = 26); and HH-T (n = 19). Median follow-up was longer among the HJ (63 months) than the other groups (32 months in HH and 25 months in HH-T; P = .04). Bile leaks developed in 8 of the HJ cases (44%); 9 of the HH cases (33%); and 1 of the HH-T cases (5%; P = .02). All cases with bile leaks (n = 18) were treated using continuous drainage, 15 of them (83%) successfully. BS developed in 4 HJ cases (22%); 12 HH cases (46%), and 4 HH-T cases (21%; P = .12). Intervention for BS (n = 20) was successful in 10 cases (50%) via an endoscopic approach and 6 cases (30%) via a percutaneous transhepatic approach. Operative management for BS was required in 4 cases (20%). Biliary reconstruction using HH-T may be effective to prevent bile leaks after LDLT. However, HH-T may not decrease the incidence of BS after adult LDLT.

Early regular examination of biliary strictures by endoscopic retrograde cholangiography for duct-to-duct biliary reconstruction after adult living donor liver transplantation.

In September 2006, we initiated regular screening of biliary strictures (BS) by endoscopic retrograde cholangiography (ERC) within 6 months after removal of external stents among duct-to-duct biliary reconstructed adult living donor liver transplantations (LDLT). From March 2000 to January 2008, we retrospectively evaluated 45 primary adult LDLTs who had survived >1 month. We separated the cases into 2 groups-the early cases (March 2000 to August 2006: n = 34) and the late cases (September 2006 to January 2008: n = 11)-to compare the incidences of BS and the success rates of endoscopic treatments. Median follow-up of the late cases (8.0 months) was shorter than that of the early cases (38.5 months; P = .0003). The overall incidence of BS was 36% (16/45), with 32% (11/34) among the early and 45% (5/11) among the late cases (P = .18). BS was successfully treated by endoscopic management in 4/5 (80%) late cases and 3/11 (27%) early cases (P = .049). Two early patients required operative biliary reconstructions. Endoscopic procedure-related complications developed in 2 patients among the early cases. Early postoperative regular screening of BS by ERC for duct-to-duct biliary reconstructions may be effective to avoid surgical interventions after adult LDLT. However, repeat ERCs have a risk for pancreatitis and other complications. Further investigations and longer follow-up are needed to confirm the efficacy and safety of a regular examination by ERC for duct-to-duct biliary reconstructions in LDLT.

De novo autoimmune hepatitis after living donor liver transplantation in a 25-day-old newborn baby: a case report.

De novo autoimmune hepatitis (AIH) has been described recently as a new type of graft dysfunction in pediatric patients receiving liver transplantation. Herein we have reported the case of a boy, diagnosed as neonatal hemochromatosis, who received a reduced left lateral graft 25 days after birth. Pretransplantation autoantibodies and serological tests were negative. The postoperative course was smooth. No episode of vascular or biliary complication or acute cellular rejection was observed. The maintenance immunosuppressant was tacrolimus only. Liver dysfunction occurred 13 months after living donor liver transplantation. Liver biopsies showed no acute cellular rejection, but severe apoptosis and regeneration of liver cells at the centrolobular area. At that time, various autoantibodies including anti-nuclear, anti-double-stranded DNA, and anti-smooth muscle antibodies were positive. In addition, serum immunoglobulin G (IgG) was elevated. Based on these findings, he was diagnosed as de novo AIH. The treatment consisted of reducing the tacrolimus dose and reintroduction of steroids. After 12 months of treatment, liver dysfunction improved, serum autoantibodies became negative, and serum IgG level normalized. Currently his immunosuppressive therapy consists of low-dose tacrolimus and prednisolone. In conclusion, the present case demonstrated that de novo AIH can appear in living donor liver transplant patients despite appropriate immunosuppression. Reducing the tacrolimus dose and reintroduction of prednisolone sustained the graft and prevented retransplantation.

Coagulation and fibrinolytic systems during liver regeneration in the early period after adult living related partial liver transplantation.

In this study, we investigated the differences in the perioperative blood coagulation and fibrinolytic systems (BCF) between donor and recipient after adult living related partial liver transplantation (ALRPLT), with particular reference to serum plasminogen-activator inhibitor-1 (PAI-1) and soluble fibinogen level. The BCF were unstable in the recipient compared with the donor. The recipient fibrinolytic system was the same as the donor system except for PAI-1, which was remarkably increased on day 1 after transplantation in the recipient. The recipient is thought to have disseminated intravascular coagulation in the early period after ALRPLT. Soluble fibrinogen may be a useful marker for improvement in the BCF system. The elevation of PAI-1 in recipients on day 1 after transplantation may be a marker of injury from the shear stress from excessive portal hypertension after ALRPLT.

Thrombotic microangiopathy after ABO-incompatible living donor liver transplantation: a case report.

Thrombotic microangiopathy (TMA) has rarely been reported in the setting of liver transplantation. Herein we have reported a successful case of TMA after ABO-incompatible living donor liver transplantation (LDLT) treated with plasma exchange and high-dose intravenous gamma-globulin infusion. A 50-year-old woman was diagnosed with hepatitis C virus-related cirrhosis. We performed an ABO-incompatible LDLT (group B to O) with preoperative plasma exchange to reduce the anti-B hemagglutinin titers to 1:8. The immunosuppressants consisted of tacrolimus, mycophenolate mofetil, and steroid. On postoperative day (POD) 8, her anti-B hemagglutinin titer suddenly increased to 1:64. The serum lactate dehydrogenase (LDH) level was grossly elevated (1518 IU/L). On POD 13, we suspected infection of an intra-abdominal hematoma (Serratia marcescens) which was drained surgically. On day 5 after the reoperation, thrombocytopenia developed with a platelet count of 3 x 10(4)/mm3. A peripheral blood film showed severe red blood cell (RBC) fragmentation. Thus, we made a clinical diagnosis of TMA and reduced the tacrolimus dose. We started intensive daily plasma exchange (4 L/d) with fresh frozen plasma and high-dose intravenous gamma-globulin infusions. One week thereafter, thrombocytopenia improved with reduced transfusion requirements. The peripheral blood film showed normal RBC morphology. The serum LDH returned to baseline levels. Four factors were considered to have caused TMA in this case: the prescription of tacrolimus, ABO-incompatible liver transplantation, bacterial infection, and surgical stress. These factors may have all contributed by causing significant endothelial injury and TMA.

Living related pancreas transplantation alone with enteric drainage in Japan: case report.

In this study, we report a living donor partial pancreas transplantation using intraportal donor-specific leukocyte transfusion (DSLT). The recipient was a 38-year-old woman who had type I diabetes mellitus for 17 years. Hypoglycemia occurred 2 or 3 times per week. Her hemoglobin A1c level was 9.0%, and she required 70 U of insulin almost every day. The donor was her 64-year-old father. The steroid-minimized immunosuppressive protocol included 1.5mg of thymoglobulin administered with a steroid bolus on days 0, 4, and 7 postoperatively. Steroids were never prescribed thereafter. Postoperative maintenance therapy included tacrolimus (FK506) and mycophenolate mofetil. In addition to these conventional approarches, we administered intraportal DSLT on days 0, 1, 4, and 7 after transplantation. The donor-specific leukocytes (40mL) had been separated from donor whole blood using an apheresis filter (Cellsorba EX; Asahi Kasei medical Co, Ltd, Tokyo, Japan). In the recipient operation, a segmental pancreas graft was transplanted into the right iliac cavity with enteric drainage with a pancreatic duct stent. Operation time was 6 hours. The postoperative course was uneventful. The patient was discharged on day 15 after transplantation. There was no acute rejection for six months after transplantation. The hemoglobin A1c level recovered to 5.1% with 6 U of insulin per day. At immunologic analysis, only interleukine-10 cytokine production was elevated at 7 days after transplantation. At flow cytometry cross-match analysis, the immunoglobulin M antibody decreased from day 7 after transplantation. We conclude that intraportal DSLT may be an effective adjunct to a steroid-free regimen.

Adult ABO-incompatible liver transplantation by intraportal transfusion of donor-specific antigen: a case report.

A 55-year-old-woman suffering from fluminant hepatitis owing to autoimmune hepatitis underwent ABO-incompatible liver transplantation (LRLD) of blood type A to B. In this study, we investigated whether a new immunosuppressive strategy by intraportal transfusion of donor-specific leukocytes (DSLT) separated from whole blood would yield immunological benefit in adult ABO-LRLD. The operative course was uneventful; she was discharged at 46 days postoperatively without humoral or cellular rejection. On immunologic analysis, 54.6% intrahepatic macrochimerism of donor type CD56+ T cells was recognized at 1 month after transplantation. The interleukin-10 Th2 cytokine level was increased on postoperative day 1. Adult ABO-incompatible liver transplantation can be performed with acceptable patient and graft survival rates with a low risk of antibody-mediated rejection with our strategy of immunosuppression by intraportal administration of DSLT. Donor type CD56+ NKT cells may induce tolerance by a veto mechanism and/or an anti-idiotype network. ABO-incompatible liver transplantation may be improved by this strategy.

Temporary cardiac pacing for fatal arrhythmia in living-donor liver transplantation: three case reports.

Cardiac pacing often turns out to be the only effective treatment of severe, life-threatening arrhythmias. We performed 77 living-donor liver transplantations (LDLT) from 1999 to 2007. In these cases, three recipients experienced fatal arrhythmia and required temporary cardiac pacing during the perioperative period. The first case was a 68-year-old woman diagnosed with liver cirrhosis and hepatocellular carcinoma (HCC). Her Model for End-Stage Liver Disease (MELD) score was 34. We performed LDLT using a right lobe graft. She showed complete atrioventricular block with cardiac arrest at postoperative day (POD) 42 after a bacterial infection. We performed a resuscitation and instituted temporary cardiac pacing. However, she was dead at POD 43. Pathologic findings at autopsy showed a diffuse myocardial abscess, which caused the fatal arrhythmia. The second case was a 58-year-old man diagnosed with HCC and liver cirrhosis; his MELD score was 9. We performed LDLT using a right lobe graft. He showed atrial fibrillation after septic shock. He also showed sinus bradycardia with a cardiac arrest at POD 10. We performed resuscitation and emergent temporary pacing. He recovered and was alive without recurrence of arrhythmia or infection. The third case was a 58-year-old woman diagnosed with multiple HCC. During preoperative regular check-up, she was diagnosed to have cardiac hypertrophy and was started on beta-blockers as treatment for cardiac hypertrophy. However, severe bradycardia necessitated temporary cardiac pacing. LDLT was performed safely after implantation of a pacemaker. Early use of temporary cardiac pacing for severe arrhythmias may be effective to maintain the hemodynamic state in LDLT.

Successful super-small-for-size graft liver transplantation by decompression of portal hypertension via splenectomy and construction of a mesocaval shunt: a case report.

We performed a successful super-small-for-size graft liver transplantation by decompressing portal hypertension via splenectomy and a mesocaval shunt. A 46-year-old woman with Child-Pugh class C liver cirrhosis associated with Wilson's disease underwent a living donor liver transplantation (LDLT). The donor had an anomalous portal vein, hepatic vein, and bile duct, so we had to use the right lateral segment for the graft. Preoperative computed tomographic (CT) volumetry showed the volume of this area to be 433 mL; graft-to-recipient weight ratio (GRWR) was 0.72; and graft-to-standard liver volume (GV/SLV) was 39.0%. However, the real volume of the resected right lateral segment was 281 g; GRWR was 0.47; and GV/SLV was 25.3%--a super-small-for-size graft. After implantation, congestion of the small graft was severe due to excessive portal hypertension. Therefore, we tried decompressing the portal vein. First, we performed splenectomy which reduced the portal pressure which remained excessive. Second, a mesocaval shunt was constructed decreasing the portal pressure from 38 to 30 cm H2O. Additionally, we initiated continuous portal injection of prostaglandin E1. The postoperative course was not smooth, but the general status slowly recovered. Over 25 cm H2O of portal hypertension was observed until postoperative day 21 when it improved. At last, the recipient was discharged on postoperative day 156. Accurate preoperative CT volumetry is important to obtain sufficient graft volume. Our case may be one of the smallest-for-size grafts that was successfully transplanted. Management of excessive portal hypertension is important for LDLT, especially using a small-for-size graft. Splenectomy and construction of a mesocaval shunt may be useful strategies to decompress the portal vein.

Successful management of a type 2 diabetic donor in living-donor liver transplantation: a case report.

A 50-year-old woman with a 4-year history of type 2 diabetes history was treated with nateglinide (270 mg/day) and metformin hydrochloride (500 mg/day). The recipient was her 55-year-old husband whose diagnoses were liver cirrhosis with type C chronic hepatitis (Child-Pugh C, score, 10; Model for End-Stage Liver Disease: 15), hepatocellular carcinoma (solitary, 2 cm), and hepatic encephalopathy. Her body weight was 50 kg and body mass index 21.6 kg/m2. Laboratory examinations showed fasting blood glucose of 110 mg/dL and hemoglobin A1c (HbA1c) of 6.6% upon admission. Right liver lobectomy was performed of a 563-g graft. Operative time was 253 minutes and blood loss 50 mL. She was discharged at postoperative day 9 without any complications. We changed nateglinide and metformin hydrochloride to insulin aspart or human insulin after admission. Blood glucose level was strictly controlled using a sliding scale of insulin. She received regular glucose check-ups at our outpatient clinic after discharge. She stopped using insulin and returned to nateglinide and metformin hydrochloride on postoperative day 25. Her blood glucose level was 80 to 150 mg/dL and HbA1c was 5.8% at 5 months after surgery. This type 2 diabetic living liver donor showed good control of the postoperative glucose level without exacerbation or diabetic complications.