Complication Follow-up With Ultrasonographic Analyses of 91 Cases With Donor Gallbladder Preservation in Living Donor Liver Transplantation of Left Lateral Sectionectomies.

BACKGROUND: Preserving the donor's gallbladder during living donor liver transplantation (LDLT) is a better method for liver transplantation surgery, but not enough is known about gallbladder complications after the operation. METHODS: We retrospectively investigated postsurgical donor gallbladder complications in clinical LDLT with gallbladder preservation. The feasibility of retaining the gallbladder during liver graft procurement is discussed. Ninety-one donors with retained gallbladder after LDLT with the hepatic left lateral sectionectomy (from June 2013 to October 2015) were retrospectively analyzed. Donors were followed for 12.6 to 40.7 months after surgery (median 26.1 months). Sonography was used to evaluate gallbladder characteristics before and after surgery. RESULTS: Gallbladder function had recovered to almost normal 1 month after transplantation. Four donors (4.40%) experienced gallbladder enlargement that resolved after 3 days. Thickening of the gallbladder wall in 31 donors (34.07%) was restored within 2 to 75 days. Biliary sludge appeared in 9 donors (9.89%); 6 of them recovered within 3 to 34 days. Three (3.30%) and 1 donor (1.10%) suffered gallstone and gallbladder polyps, respectively, which persisted until the last follow-up. CONCLUSION: The rate of postoperative complications of the gallbladder in donors was relative low. Preserving the gallbladder in liver transplantation donors during liver graft procurement is feasible and safe.

[Hepato-pancreato-biliary (HPB) surgery and abdominal organ transplantation, a defined subspecialty, integrated within the surgical division: professional, operative and educational aspects].

INTRODUCTION: EstabLishment of hepato-pancreato-biliary (HPB) surgery and abdominal organ transplantation as defined subspecialties of general surgery has been boosted over the Last decade. However, the affiliation (independent service vs. integration within the division of surgery), the training course (transplantation vs. surgical oncology) and the referral patterns are still controversial. METHODS: Dedicated HPB and transplantation units were defined within the surgical division of the Tel Aviv Medical Center. The principles of operation included muttidisciplinary expert teams, unified and standard treatment protocols, exposure and involvement of all residents and attending surgeons of the division to patients, decision-making and perioperative care, peer review and periodic publication of clinical results. RESULTS: Between the years 2003-2007, 870 major HPB procedures were performed: 70 Liver transplants (9 from live donors), 100 organ procurements, 165 kidney and kidney-pancreas transplants (30% from Live donors), 250 hepatic resections of various types and indications, 35 complex biliary reconstructions and 250 pancreatectomies. The short- (morbidity and mortality) and long-term (survival and disease free survival) rates are compatible with the reported results from Centers of Excellence around the world. CONCLUSIONS: Operating HPB and transplantation surgery by trained experts and defined professional units, but within an academic surgical division, promotes the achievement of high volume and excellent results together with optimal exposure, education and training of the surgical residents.

Gallbladder epithelial cells that engraft in mouse liver can differentiate into hepatocyte-like cells.

We tested the hypothesis that well-differentiated gallbladder epithelial cells (GBECs) are capable of engrafting and surviving in murine liver and acquire phenotypic characteristics of hepatocytes. GBECs isolated from transgenic mice that constitutively express green fluorescent protein (GFP) were either cultured before transplantation or transplanted immediately following isolation. Recipient mice with severe-combined immunodeficiency underwent retrorsine treatment and either partial hepatectomy before transplantation or carbon tetrachloride treatment following transplantation. From 1 to 4 months following transplantation, the livers of recipient mice contained discrete colonies of GFP(+) cells. Most GFP(+) cells surrounded vesicles, were epithelial cell-like in morphology, and expressed the biliary epithelial markers cytokeratin 19 and carbonic anhydrase IV. Subpopulations of GFP(+) cells resembled hepatocytes morphologically and expressed the hepatocyte-specific markers connexin-32 and hepatic nuclear factor-4alpha, but not cytokeratin 19 or carbonic anhydrase IV. At 4 months, cells in GFP(+) colonies were not actively proliferating as determined by proliferating cell nuclear antigen expression. Thus, GBECs are capable of engrafting and surviving in damaged mouse livers, and some can differentiate into cells with hepatocyte-like features. These findings suggest that environmental cues in the recipient liver are sufficient to allow a subpopulation of donor GBECs to differentiate into hepatocyte-like cells in the absence of exogenous transcriptional reprogramming. GBECs might be used as donor cells in a cell transplantation approach for the treatment of liver disease.

A method for culturing and transplanting biliary epithelial cell from syrian golden hamster.

The present paper describes the establishment of a method for simultaneous culturing of biliary epithelial cells (BECs) from the gall bladder (GB), extrahepatic bile duct (EBD) and intrahepatic bile duct (IBD) of the hamster. GB, EBD and IBD were cut from the biliary tree after collagenase perfusion of the liver. These biliary segments were minced into fragments. The fragments were embedded in collagen gel and cultured in Dulbecco's modified Eagle medium/HamF12 medium containing 10% fetal bovine serum. The various cells subsequently spread from the fragments and formed cellular sheets. After the fragments and flattened cells were removed with the aid of a Pasteur pipette under phase-contrast microscopy, the sheets remaining were found to be composed of cuboidal cells. These cuboidal cells were shown to express gamma glutamyl transpeptidase and cytokeratin 7, which are known to be specific markers of BECs. Ultrastructurally, a large number of microvilli were observed on the luminal surface and junctional complex and interdigitation was identifiable on the lateral surfaces. BEC cultures were subcultured by digestion with collagenase and dispase and then dissociated by subsequent digestion in trypsin and ethylenediaminetetraacetic acid and then maintained on collagen gel for up to 8 weeks. After several passages, the BECs in culture eventually increased in size and showed vacuoles in the cytoplasm. They demonstrated irreversible growth arrest at 9 weeks. The BECs tended to form cystic structures when the BECs with collagen gel were transplanted into the interscapular fat pads of syngeneic hamsters. We established a method for culturing and transplanting biliary cells from syrian golden hamsters. This method may help to clarify the mechanism of hepatobiliary diseases.

Small bowel rejection in isolated small bowel transplantation and in multivisceral transplantation: a comparative study in a large animal model.

The proposition that a combined graft including the liver protects other organ allografts from the same donor is well known. However, it is not evident in the clinical results. The present experiments were undertaken to compare acute small bowel rejection in isolated small bowel transplantation with multivisceral transplantation. Using 36 outbred, male Large-White pigs, isolated small bowel transplantation (SBTX: n = 9) and abdominal multivisceral transplantation (MVTX: n = 9) were performed without immunosuppression. The survival rate and blood serum samples were monitored postoperatively. In order to compare acute small bowel rejection, sequential biopsy specimens from Thiry-Vella loops were also monitored daily beginning on me 3rd day after transplantation. The specimens were scored from 0 to 3 according to the severity of the rejection. The survival rate was not significantly different. However, significant differences were noted in the cause of the death and in the pathologic changes of the small bowel. In contrast to SBTX, the small bowel rejection of MVTX was significantly delayed and less severe. The rejection score of MVTX was significantly better than SBTX from 5 postoperative days (POD) to 1 lPOD (P < 0.05). The present study demonstrated mat acute small bowel rejection of MVTX graft including the liver was delayed and less severe than that of SBTX in an outbred large animal model.

Vesica fellea--a new substitute for the bladder? An experimental study.

The urinary bladders of 8 dogs were removed and replaced with their own gallbladders using microvascular anastomoses. Post-operative assessment included measurement of blood urea nitrogen (BUN) and creatinine (Cr), intravenous urography and histological examination of the autotransplanted gallbladders. The neobladders proved to be good reservoirs without urinary leakage. Renal function was well preserved in 6 dogs; post-operative BUN and Cr levels were raised in 2 dogs and the concentrating ability of the kidneys was reduced. The neobladders were perfect histologically.

[Abdominal multi-organ transplantation in dogs].

Abdominal multi-organ transplantation including the liver, gallbladder, spleen, pancreas, kidneys, adrenal glands and gastrointestinal tract was attempted in 8 dogs. Each experiment was discontinued when the recipient deteriorated. Immersion hypothermia was introduced in both the donor and recipient until the esophageal temperature reached 27-30 degrees C. Whole abdominal organs of the donor were removed in an en-bloc fashion at 20 degrees C of the graft temperature after additional cooling by ice slush scattering into the abdominal cavity. Transplantation was carried out orthotopically in the following sequence: (1) the proximal aorta, (2) suprahepatic vena cava, (3) distal aorta, (4) infrahepatic vena cava. The alimentary tract was reconstructed by gastro-gastrostomy and colo-colostomy. The ureters were implanted in the bladder. Cold ischemic time of the graft was about 40 minutes. Heparin was not used throughout the procedure. Five out of eight dogs were alive for more than 24 hours and two of them survived for 60 hours with good recovery. No immunosuppressant was given. Though the result in the present study was far from satisfaction, the experiment may provide a possibility of a new experimental model for transplantation, especially regarding pathophysiology and interrelationship of the transplanted complex organs.

[Long-term maintenance of human gall-bladder epithelia as xenografts following explant organ culture].

The purpose of present study is to establish a method that should enable us to keep a human gall-bladder epithelial tissue alive for a period long enough to observe morphological change after an exposure to a certain carcinogenic agents. Human gall-bladder epithelia obtained from surgically resected specimen were kept as an explant organ culture in vitro for the first 2 weeks. They were, then, xenotransplanted to the subcutaneous (S.C.) space of the athymic nude mice. The gall-bladder tissues obtained from 7 cases of cholecystolithiasis and 1 case of cholecysto-choledocholithiasis were used as materials in the present study. And the longest survivor among them in the nude mice was extensively studied in the present paper. After an interval of 4 to 27 weeks, the xenografts were recovered from the recipient mice and studied by light microscopy and histochemistry. The morphological changes of the explant epithelia during the organ culture were also studied. Parts of the explants were implanted in 6 nude mice. Each of the mice received 3 pieces of explants on the s.c. space in both of their flanks. All xenografts showed subcutaneous cyst formation. The cyst obtained 4 weeks after the implantation was consisted of a monolayer of cuboidal epithelial cells and those recovered from the recipient mice 24 and 27 weeks after the implantation were consisted of well growing columnar and cuboidal epithelial cells. In addition, sinus-like structures were observed beneath the cystic epithelia. The viability of the cells was excellent.(ABSTRACT TRUNCATED AT 250 WORDS)

[Replacement of the choledochus with autologous vascularized gallbladder]. / Ersatz des Gallengangs mit autologer vaskularisierter Gallenblase.

Multiple experiments to replace the extrahepatic bile duct by autologous or homologous and alloplasty failed until now. The possibility to employ autologous gall bladder as replacement for the common bile duct has been examined in animal experiments. With the supposition of primary vascularization and the adaptation of the luminal proportion of the transplant to the common bile duct, it could be demonstrated that a flapped, tubular gall bladder interposition kept its epithelium and, by this way, showed no shrinkage or stenosis. The functionaal performance of this method has been confirmed by clinical, laboratory, radiological, and bacteriological, as well as micro- and macropathological experiments.

Partial replacement of urinary bladder by autologous gallbladder.

In an effort to find a more suitable method of partial urinary bladder replacement for those patients with either a damaged or contracted bladder, the use of the autologous gallbladder was studied. The urinary bladders of 6 female dogs were partially resected, and the defective portions were replaced by autologous gallbladder transplants. After six weeks, the gallbladder mucosa showed evidence of squamous cell metaplasia progressing toward transitional cell epithelium with minimal necrosis. The muscular layer showed extensive granulation tissue and revascularization. No changes were detected in the upper urinary tracts. No mortality or detectable morbidity was associated with the procedure. It appears that the gallbladder may have a role to play in partial urinary bladder replacement.

A new technique for biliary drainage in orthotopic liver transplantation utilizing the gall bladder as a pedicle graft conduit between the donor and recipient common bile ducts.

A technique for biliary drainage in orthotopic liver transplantation has been developed in which the gall bladder is used as a pedicle graft between the donor and recipient common bile ducts. In 7 patients this technique has produced encouraging results. There has been no incidence of bile leakage or stenosis of the anastomoses. The gall bladder permits the widest possible anastomoses for obliquely cut ends of the donor and recipient common ducts. It eliminates tension and retains the advantage of the sphincter of Oddi. Although the followup is short, the incidence of biliary complications using other techniques has been so high that the procedure described here would appear to have distinct advantages.

Repair of common bile duct defects using the gallbladder or cystic duct as a pedicled graft.

To repair defects in the common bile duct, part of the gallbladder and the cystic duct may be used as a pedicled graft. This has the advantage of an independent blood supply and a related mucosal lining. The method is illustrated by four patients who had excellent primary and short term results. In two patients, the defect was due to large cholecystocholedochal fistulas caused by migrating large gallstones. In one patient with marked stenosis of the duct, the defect occurred when the stenosis was opened through a longitudinal incision. The fourth patient had a large duodenal ulcer that penetrated into the common duct, causing a defect that could not be closed by suture. A definite evaluation of the procedure must await a longer period of follow-up study.