A modified right liver graft can provide satisfactory surgical results if hepatic vein reconstruction and plasty are performed using the present techniques.

The present preemptive antiviral protocol after LDLT is safe and might warrant a controlled study for confirming its benefit on graft survival.

Right-lobe graft has been used most frequently for living donor liver transplantation in adult patients; however, some donors cannot donate their right lobe (according to the Healey and Scroy's terminology) because the remaining residual liver would be too small. A recent study suggested the possibility of right posterior segment graft in these donors. The purpose of this study was to evaluate the feasibility of right lobe or right posterior segment graft with a volumetric analysis. Liver volumetry by computed tomography was performed in 155 consecutive donors, and the volume of each liver segment was calculated. To confirm the reliability of volumetric examination, the estimated graft volume and the actual weight were compared. The average volume ratios of the lefi lateral segment, lefi medial segment, caudate lobe, right anterior segment, and right posterior segment were 17%, 14%, 2%, 37%, and 30%, respectively. In 39 donors (25%), the volume ratio of the right lobe was over 70%. Of Tokyo, However, right lobectomy could impose a higher surgical risk on donors, as reflected by the volume of the residual liver mass. Furthermore, not all donors can provide their right lobe. Fan and associates* concluded that safe donation was possible only when the estimated residual liver volume was over 30%. Although it should be considered an important criterion to maintain donor safety, the proportion of donors whose right lobe volume ratio is over 70% remains unclear.Recently, to overcome this problem, the right posterior segment graft was introduced as an alternative liver graft.5 However, its feasibility remains obscure because nobody knows with acceptable probability whether the right posterior segment can provide a larger mass than the lefi lobe.To resolve these questions, volumetric analysis of each liver segment was performed. The estimated liver segment volume and actual graft weight were compared to confirm the reliability of volumetric examination. Materials and MethodsBetween January, 1996 and December, 2001, 155 LDLT procedures were performed at Tokyo University Hospital under approval of the Ethics Committee. The recipients consisted of 68 children (younger than 18 years of age) and 85 adults (1 8 years old or more). The patients ranged in age from 8 months to 64 years (mean, 27 years) with body weights ranging from 6 to 99 kg (mean, 39 kg).The underlying condition was biliary atresia in 65, primary biliary cirrhosis in 30, liver cirrhosis for hepatitis with or without hepatocellular carcinoma in 2 l , fulminant hepatic failure in nine, metabolic disorders in seven, and other conditions in 2 1.The remaining two patients underwent retransplantation for graft failure.The donors consisted of 78 parents, 36 children, 20 siblings, 12 spouses, grandmothers, uncles, nieces, and nephews in two, each, and one cousin. The donors ranged in age from 20 to 63 years (mean, 37 years) and weighed from 42 to 90 kg (mean, 61 kg). Segments harvested included left lateral segment (n = 35), extended lefi lateral segment (n = 15), ...

Heparin is widely used to reduce the incidence of vascular thrombosis after liver transplantation. Appropriate use of heparin based on changes in coagulation and fibrinolytic profiles, however, has not yet been discussed in detail. We performed living-donor liver transplantation for 128 adult patients. In this series, dalteparin (25 IU/kg/d) was administered until post-operative day (POD) 2. On POD 3, the anticoagulant drug was changed to heparin (unfractionated heparin sodium, 5000 U/d), the dose of which was changed according to the level of activated clotting time (ACT) targeted between 130 and 160 s. The plasma level of plasmin-alpha2 plasmin inhibitor complex, thrombin-antithrombin III complex (TAT), and fibrin degradation product D-dimer (FDP-DD) were monitored in the 21 patients. Predictors for heparin doses were analyzed among clinical parameters (n = 128). Four patients (3%) were complicated with thrombosis despite the above-mentioned anticoagulation protocol. Transfusion and/or relaparotomy for hemostasis were necessary for bleeding in 19 patients (15%). The TAT level markedly elevated until POD 3 and FDP-DD peaked later. The required heparin dose to maintain adequate ACT levels increased linearly until POD 8, and kept constant thereafter, which correlated with the weight of the liver graft (p = 0.01). Thus, frequent monitoring of the heparin dosage is necessary to keep the ACT level in the target range in the first post-operative week. High hemorrhage complications in our series indicate that the lower target ACT range may be preferable in the second post-operative week.

There are no detailed studies on the prevalence or clinical magnitude of bloodstream infection (BSI) following living donor liver transplantation (LDLT). The study aimed to assess the incidence and analyze the risk factors for BSI after LDLT. Univariate and multivariate analyses were performed to identify the independent risk factors for postoperative BSI. Postoperatively, 26 episodes of BSI occurred in 21 of 242 studied adult patients by median postoperative d 35. Five patients had primary BSI. The source was unknown in 3 patients and an intravascular catheter in 2. The other 16 patients had secondary BSI. Secondary BSI was caused by surgical site infection in 8 patients, followed by intra-abdominal infection in 5, pneumonia in 2, and both surgical site infection and intra-abdominal infection in 1. The most frequent pathogen isolated was MRSA, which was detected in 4 patients. Surveillance culture detected the same isolates prior to BSI in 14 of 26 (50%) episodes. Diabetes mellitus and serum albumin level less than 2.4 g/dl independently predicted postoperative BSI. Perioperatively, screening for and taking actions against pathogen including MRSA should be performed in LDLT patients.

No data are available for the management of venous jump or interposition conduits for portal vein (PV) reconstruction in adult living donor liver transplantation (LDLT). The feasibility of using cryopreserved vein grafts as PV conduits was examined. Cryopreserved vein (n ϭ 23) was used as a patch, interposition, or jump graft. The patency results were compared with those of anastomosis without vein patch (n ϭ 217) or those with vein autografts (n ϭ 10). The 5-yr primary and secondary patency rates of the cryopreserved vein grafts were 58% and 79%, respectively. In conclusion, our data indicate that the use of cryopreserved vein grafts should be limited as conduits in PV reconstruction in adult LDLT. Liver transplantation utilizing living donors is now well established for the treatment of end-stage liver disease. 1 The benefits include improved timing of transplantation, improved graft quality, and increased donor supply. This procedure, however, poses unique challenges in vascular reconstruction, resulting in more frequent vascular complications. 2 Functional vascular reconstruction is crucial to the long-term success of liver transplantation. Portal vein (PV) reconstruction is particularly important for graft survival because the completion of this anastomosis ends both the ischemic period for the donor liver and the anhepatic period for the recipient. 3 The most common PV reconstruction techniques involve maximizing the length of the recipient PV that is retained through use of the recipient PV bifurcation. 4 When end-to-end PV reconstruction is impossible, for example, due to preoperative PV thrombosis, a venous jump or interposition conduit must be obtained. In deceased donor liver transplantation, vein grafts are obtained from the same donors. 5 In living donor liver transplantation (LDLT), however, there are ethical considerations with regard to harvesting vein grafts from the same donors. A previous report 6 pointed out potential problems in LDLT. Surprisingly, a recent large series on adult LDLT 3,4,7 did not describe the management of venous jump or interposition conduits for PV reconstruction. To overcome this problem, we adopted the use of cryopreserved vein grafts as PV conduits in adult to adult LDLT. To examine the feasibility of this technique, the patency data were examined and compared with those of anastomosis without vein grafts or autografts.Abbreviations: LDLT, Living donor liver transplantation; PV, portal vein.

Functional studies have yet to be undertaken to establish which brain region subserves the parasympathetic regulation of the cerebral circulation. Using 31 anesthetized rats with precluded cervical sympathetic trunks, we therefore attempted to perform chemical stimulation of the greater petrosal nerve (GPN) cell group, which is a subgroup of the superior salivatory nucleus and sends off axons largely to the parasympathetic pterygopalatine ganglion via the GPN component of the facial nerve. The cerebrocortical blood flow was monitored with a laser-Doppler flowmeter. Unilateral stimulation of the GPN cell group by microinjection of L-glutamate reduced the ipsilateral cerebrocortical vascular resistance, maximally by 16.4 +/- 4.1% (mean +/- SD, n = 61). The response was not mediated by the classic muscarinic receptors of the cerebral vessel wall. However, pharmacological blockade of the peripheral parasympathetic ganglia and acute and chronic bilateral removal of the parasympathetic postganglionic fibers originating in the pterygopalatine ganglion abolished the response. The present data thus provide functional evidence that the GPN cell group may constitute a parasympathetic cerebrovasodilator center.

Summary Successful management of portal vein (PV) complications after liver transplantation is crucial to long‐term success. Little information is available, however, regarding the incidence and treatment of PV complications after adult‐to‐adult living donor liver transplantation (LDLT). Between January 1996 and October 2006, 310 adult LDLTs were performed at our institution. PV thrombus was present in 54 patients at the time of LDLT. The incidence of PV complications, choice of therapeutic intervention, and outcomes were retrospectively analyzed. Among the 310 recipients, PV complications were identified in 28 (9%). Risk factors included smaller graft size, presence of PV thrombus at the time of LDLT, and use of jump or interposition cryo‐preserved vein grafts for PV reconstruction. When divided into early (within 3 months, n = 11) and late (after 3 months, n = 17) complications, the use of vein grafts for PV reconstruction predisposed to the occurrence of late, but not early, PV complications. Portal vein thrombosis occurred more frequently in the early period (eight out of 11, 73%), whereas stenosis occurred more frequently in the later period (14 out of 17, 82%). Surgical interventions were favored in the earlier period, whereas interventional radiologic approaches were selected for later events. Overall 3‐ and 5‐year survival rates were 81% and 77%, respectively, in patients with PV complications and 88% and 84%, respectively, in those without PV complications (P = 0.21, log‐rank test). PV complications are a significant problem following LDLT with both early and late manifestations. Acceptable long‐term results, however, are achievable with periodic ultrasonographic surveillance and timely conventional therapeutic interventions. The use of cryo‐preserved vein grafts for reconstructing portal flow should be discouraged.