Search

Objective: To define the technical factors that might contribute to hospital mortality of recipients of right lobe live donor liver transplantation (LDLT) so as to perfect the design of the operation. Summary Background Data: Right lobe LDLT has been accepted as one of the treatments for patients with terminal hepatic failure, but the design and results of the reported series vary and the technical factors affecting hospital mortality have not been known. Methods: The data of 100 adult-to-adult right lobe LDLT performed between 1996 and 2002 were prospectively collected and retrospectively analyzed. All grafts except one contained the middle hepatic vein, which was anastomosed to the recipient middle/left hepatic vein in the first 84 recipients and directly into the inferior vena cava (with the right hepatic vein in form of venoplasty) in the subsequent 15 patients. Venovenous bypass was used routinely in the first 29 patients but not subsequently. Results: Eight patients died within the same hospital admission for liver transplantation. There was no hospital mortality in the last 53 recipients. Comparison of data of patients with or without hospital mortality showed that graft weight/body weight ratio, graft weight/ estimated standard liver weight ratio, technical error resulting in occlusion/absence of the middle hepatic vein, use of venovenous bypass, the lowest body temperature recorded during surgery, the volume of intraoperative blood transfusion, fresh frozen plasma, and platelet infusion were significantly different between the two groups. However, the pretransplant intensive care unit status of the recipients, cold and warm ischemic time of the graft, and occurrence of biliary complications were not. By multivariate analysis, low body temperature recorded during operation, low graft weight/estimated standard liver weight ratio (≤0.35), and the middle hepatic vein occlusion were independent significant factors in determining hospital mortality. Conclusions: To achieve a uniformly successful right lobe LDLT, the right lobe graft must contain a patent middle hepatic vein. With a completely patent middle hepatic vein, a graft size of >35% of the estimated standard graft weight may be sufficient for recipient survival. Hypothermia, which predisposes to coagulopathy and is enhanced by the use of venovenous bypass and massive blood, and blood product transfusion must be avoided., published_or_final_version

Background. The interaction between intercellular adhesion molecule-1 (ICAM-1) and its ligand, leukocyte function associated antigen-1 (LFA-1), is especially relevant in allograft rejection. We have previously shown that the simultaneous blockade of ICAM-1 and LFA-1 by monoclonal antibodies (mAbs) results in specific immunologic tolerance to cardiac allograft in a mouse model. Methods. We evaluated the roles of these adhesion molecules in xenograft rejection by using a rat-to-mouse concordant xenograft model to identify critical molecules for immunosuppression. Results. Lewis rat hearts transplanted into C3H/He mice were rejected within 5 to 7 days without treatment. A significant prolongation of xenograft survival (mean survival time, 11.6 days) was observed after treatment with anti-rat ICAM-1 and anti-mouse LFA-1 mAbs, when compared with nontreated mice or mice, treated with different combinations of mAbs. Graft survival was prolonged in mice treated with FK506 (1 mg/kg/day), anti-rat ICAM-1, and anti-mouse LFA-1 mAbs (mean survival time, 22.2 days), whereas the same dose of FK506 alone was not effective. The mixed lymphocyte reaction showed that a combination of mAbs against mouse LFA-1-rat ICAM-1 and rat LFA-1-mouse ICAM-1 significantly inhibited the proliferation of mouse responders to rat stimulators and rat responders to mouse stimulators, respectively. Infiltration of mouse CD4 positive, mouse CD8 positive, and mouse LFA-1 positive cells, as well as dense deposition of mouse immunoglobulin G (IgG), IgM, and up-regulation of rat ICAM-1, on the graft endothelial cells were demonstrated by immunopathologic analysis of the rejected hearts. Flow cytometric analysis with rat spleen cells demonstrated the presence of xenoreactive antibodies (mouse IgG and IgM) in the recipient's serum. This xenoreactive antibody production was delayed but not inhibited by treatment of the recipients with anti-rat ICAM-1 and anti-mouse LFA-1. Conclusions. Blockade of the donor side ICAM-1 and the recipient side LFA-1 is critical for immunosuppression with anti-ICAM-1-LFA-1 treatment. Humoral factors may be responsible for xenograft rejection that occurs even after inhibition of the cell-mediated immune response by anti-ICAM-1 and anti-LFA-1 mAbs.

Heterogeneity of DNA content in multiple hepatocellular carcinomas (HCCs) was investigated by flow cytometry in 62 tumours from 26 patients who had undergone surgical treatment for multiple synchronous HCCs. Heterogeneity of DNA content was defined (a) when tumours had a different DNA ploidy pattern or (b) when the difference in the DNA index of the aneuploid clone was more than 0.1. A tumour with DNA aneuploidy was observed in 17 (66%) of the 26 patients. Heterogeneity of the DNA content was demonstrated in 12 (46%) out of 26 patients: in ten cases by definition (a) and in two cases by definition (b). Histological examination revealed that, of the 12 patients with a heterogeneous tumour DNA content, seven (58%) had a heterogeneous and the remaining five (42%) had a homogeneous type and grade of differentiation among the tumours, showing the absence of a relationship between histological heterogeneity and DNA content. The present results suggest the clinical relevance of DNA content analysis for identifying the clonal origin of multiple HCCs.

Intraportal ultrasonography (US) with scanning catheters was attempted in nine patients with various biliary tract diseases, to evaluate the portal venous system for tumor invasion. Intraportal US was performed successfully in seven patients. Intraportal US scans were compared with images obtained with arterial portography, direct portography, and intraoperative US. Intraportal and intraoperative US revealed cancer invasion into the wall of the portal venous trunk in two patients. Negative findings for cancer invasion with intraportal US were verified with intraoperative US and laparoscopic examination in five cases. Arterial portography was unable to delineate the fine portal venous wall configuration in six of the seven patients, and direct portographic images were not fully diagnostic of tumor invasion in three cases. The improved detection of tumor invasion to the portal venous system with intraportal US was helpful in determining the appropriate treatment for biliary tract disease in these patients.