Hepatic steatosis is often associated with overweight, so we tried body-weight reduction in potential living donors with fatty liver and/or obesity to alleviate hepatic steatosis. We advised to reducing the body weight by 5% for 9 potential living donors showing hepatic steatosis of 25 -95% on initial percutaneous needle biopsy (PCNB). They lost 5.9 ؎ 2.0% of the initial body weight during 2 -6 months and their body mass index changed from 25.3 ؎ 3.8 to 23.7 ؎ 3.4. Total amount of hepatic steatosis changed significantly from 48.9 ؎ 25.6% to 20.0 ؎ 16.2% before and after weight reduction. The proportional reduction in microvesicular steatosis was more obvious than in macrovesicular fatty changes. Six right lobe and 3 left lobe grafts were procured uneventfully from these 9 donors. All donors recovered uneventfully, and all 9 recipients survived more than 15 months to date. In conclusion, we think that short-term weight reduction of living donors will be helpful to alleviate excessive hepatic steatosis, especially in microvesicular type and can contribute to expand the pool of marginal living donors.

Hepatic venous congestion (HVC) has not been assessed quantitatively prior to hepatectomy and its resolving mechanism has not been fully analyzed. We devised and verified a new method to predict HVC, in which HVC was estimated from delineation of middle hepatic vein (MHV) tributaries in computed tomography (CT) images. The predicted HVC was transferred to the right hepatic lobes of 20 living donors using a paper scale, and it was compared with the actual observed HVC that occurred after parenchymal transection and arterial clamping. The evolution of HVC from its emergence to resolution was followed up with CT. Volume proportions of the predicted and observed HVC were 31.7 ؎ 6.3% and 31.3 ؎ 9.4% of right lobe volume (RLV) (P ‫؍‬ .74), respectively, which resulted in a prediction error of 3.8 ؎ 3.7% of RLV. We observed the changes in the HVC area of the right lobes both in donors without MHV trunk and in recipients with MHV reconstruction. After 7 days, the HVC of 33.5 ؎ 7.7% of RLV was changed to a computed tomography attenuation abnormality ( A right lobe without reconstruction of the middle hepatic vein (MHV) trunk has been a standard liver graft for adult-to-adult living donor liver transplantation (LDLT) in many transplantation centers. Hepatic venous congestion (HVC) caused by deprivation of MHV drainage has been tolerated in many right lobe recipients, but there has been much debate on the natural resolution of HVC as well as the need for MHV reconstruction. 1 -4 Recently, many surgeons have agreed on the need of MHV reconstruction because of occasional massive ischemic congestion, and and have become interested in criteria for MHV reconstruction. 2,5 To determine if MHV reconstruction is indicated, quantitative assessment of HVC in the right lobe becomes the most important step. However, this is feasible only after division of MHV tributaries during transsection of the parenchyma.In our 398 cases of adult-to-adult LDLT prior to this study, we observed that HVC of a right lobe occurred according to the anatomical distribution of MHV tributaries. 5 This implied that HVC might be predicted quantitatively by using a method based on hepatic vein anatomy. A pilot study for assessment of HVC using computed tomography (CT) convinced us that a new CT-based prediction method deserved a prospective trial.In this study, we verified our CT-based method for preoperative quantitative assessment of HVC and analyzed the HVC-induced changes in the liver to clarify the inducing and resolving mechanisms of HVC. Patients and Methods Pilot Study to Assess HVC Using CT Image Analysis and VolumetryOut of 398 adult LDLT cases, we selected 6 cases of right lobe graft recipients and 10 living donors of extended left lobe graft (left lobe with MHV trunk) showing extensive areas of attenuation abnormalities (computed tomography attenuation abnormality [CTAA]) of the liver parenchyma on postoperative CT. We extracted the outlines of CTAA in the graft or Abbreviations: HVC, hepatic venous congestion; MHV, middle hepatic vein; CT, compu...

The left-sided gallbladder is very rare, but it is often accompanied by multiple anomalies of the liver, by which living donor hepatectomy cannot be feasible or becomes difficult. We have experienced A left-sided gallbladder (LSGB) usually means that the gallbladder is located to the left side of the round ligament without situs inversus viscerum. Additionally, the middle hepatic vein should run to the right of the gallbladder and the round ligament itself should originate from the left portal vein to meet its definition. The incidence of LSGB was reported as 0.1-0.7% in Japan. 1 In our department, we have encountered only 5 patients with LSGB in 8,000 patients who had undergone laparoscopic cholecystectomy, 1 in 2,000 hepatectomy patients, and 1 in 250 cadaveric organ procurement during last 13 years except for living donors.We have seen this rare anomaly of LSGB in 3 donors for living donor liver transplantation among 642 living donors from 1994 to May 2003 and performed adultto-adult liver transplantation successfully using these donor liver grafts. This is the second report of living donors with LSGB. The first report was presented from Kyoto University, in which the left lobe was harvested from three living donors with LSGB. 2 Our LSGB donors showed different patterns of combined anomalies, so we had to perform different types of donor hepatectomy after mapping of the anomalies. We herein describe the characteristics of the combined liver anomalies observed in 3 living donors with LSGB and summarize the preoperative and intraoperative evaluation processes. Case Reports Case 1This living donor case was an 18-year-old son of the recipient. During preoperative evaluation of the donor, the presence of LSGB with combined anomaly was suspected on computed tomogram (CT, Fig. 1A) and selective visceral angiogram was carried out additionally. Indirect portogram revealed that there was a long neck portion of the right portal vein with poor development of the left main portal vein (Fig. 1B). A branching pattern of the hepatic arteries looked complex due to the uncommon running course of the middle hepatic artery (Fig. 1C). CT volume of the right lobe and remaining left lobe with caudate lobe were estimated as 801 mL and 556 mL, respectively. Just after laparotomy, we confirmed the anomaly of LSGB and examined the liver anatomy closely to determine its suitability as a living donor for right lobe retrieval. On intraoperative cholangiogram, the hepatic duct confluence was located near the upper margin of the duodenal first portion, at which there were extremely long extrahepatic right and left hepatic ducts (Fig. 1D). The right hepatic artery was dissected toward the origin site of the middle hepatic artery. We encircled the long transverse portion of right portal vein Abbreviations: CT, computed tomogram; LSGB, left-sided gallbladder; P4, portal vein branch to the medial segment; S4a, anterior portion of the medial segment; S4b, posterior portion of the medial segment.